‫بسم اهلل الرحمن الرحيم‬

Nile University
Faculty of Medicine
Community Medicine Department
Fifth year, Semester 1X
Research Project in Public Health Report
Batch 9, Group 3

Assessment of the implementation of IMCI Strategy in

three primary Health Care Centers, Sharg AlneeL
Locality, Khartoum, Sudan, August-October 2020

By:
Alaa Yousif Dafalla
Reham Hamad Mohamed Osman
Abubaker Mahmoud Mohamed
Mohamed Hashim

Supervisor:

Prof. Sumaia M. Alfadil

MB.BS, DPH, Diploma of Health Education and MD Community Medicine
and
Dedication:

we dedicate my thesis work to our families and many friends .A special

felling of gratitude to our loving parents, whose words of
encouragement and push for tenacity ring in our ears. Our sisters and
brothers have never left our side and are very special.
We also dedicate this thesis to our friends who have supported us
throughout the process .We will always appreciate all they have done.

I
 Acknowledgment:

First of all , we deeply grateful to Allah .Coming from intense

gratification of our supervisor sumaia alfadi who her contribution has
raised the quality of this thesis , shehas always supported us and has
given us enthusiasm for science .She has patiently guided us. We are
very grateful for her

We would like to express our special thanks of gratitude to health affairs at

locality for providing us by information ,medical directors in health centers
who allow us to conduct our study and the mothers of children and health care
providers whom dedicate their time for us and provided us by information .

II
Table of contents:

Content Page number

Dedication I

Acknowledgement II

Table of content III

List of abbreviations IV

List of tables V

List figures VI-VII

Abstract in English VIII

Abstract in Arabic IX

CHAPTER ONE :INTRODUCTION 1-5

1.1 Background 1

1.2 Problem statement 2

1.3 Rationale 4

1.4 General objective 4

1.5 Specific objective 4

1.6 Variables 4-5

CHAPTER TWO : LITERATURE REVIEW 6-8

2.1 Global level 6

2.2 Regional level 6-7

2.3 Local level 7-8

CHAPTER THREE : METHODs AND MATERIALS 9-11

3.1 Study design 9

3.2 Study population 9

3.3 Study area 9

3.4 Sampling size III 9-10

3.5 Sampling technique 10

3.6 Data collection tools 10-11

3.7 Data analysis 11

3.8 Ethical consideration 11

3.9 Work plan 11

CHAPTER FOUR : RESULTS 12-39

CHAPTER FIVE : DISCUSSION
40-41

5.1 CONCLUSION 40-41

5.2 RECOMMENDATIONS 41

5.3 limitations of the study 41

REFRENCES 42-44

ANNEXES 45-60

List of abbreviation:

Abbreviation Description
ARI Acute respiratory infection

BCG Bacilie-clamette-guerin

BP Blood pressure

DPT Diphtheria, pertussis ,tetanus

FMOH Federal ministry of health

HCP Health care provider

HEP Heamophilus

HIP Hepatitis

IMNCI IV Integrated management of newborn and

childhood illnesses

IPV Inactivated polio vaccine

MA Medical assistant
MD Medical doctor

NG Nasogastric

OPV Oral polio vaccine

OPV Pneumococcal conjugate vaccine

ORS Oral rehydration solution

ORT Oral rehydration therapy

PHC Primary Health Care

RDT Rapid diagnostic test

RTV Rotavirus vaccine

SCM Standard case management

SMOH State Ministry of Health

Vit Vitamins

List of Tables : V

Tables Title Page number

Table 1 Health centers staff medical treatment 12

Table 2 Child main complaint 12

Table 3 Distribution of caretakers according to 13

their age

Table 4 Availability of equipments 13

Table 5 Availability of drugs 14

Table 6 Availability of vaccinations 14

List of figure :

Figure Title Page number

Figure 1 Presence of volunteers in neighborhood P

Figure 2 Presence of educational home visits 16

Figure 3 Distribution of children presenting in 17

PHC centers

Figure 4 Classification of children according to 18

their gender

Figure 5 distribution of children according to 18

their age

Figure 6 Child main complaint (0-2) months 19

Figure 7 Distribution of caretakers by gender 19

Figure 8 Distribution of caretakers according to 20

their education

Figure 9 Distribution
VI of caretakers according to 20
their occupation

Figure 10 Distribution n of caretakers according to 21

their residency

Figure 11 Distribution n of caretakers according to 21

 their monthly income

Figure 12 Knowledge of caretakers about treating 22

skin pustules or umbilical infection

Figure 13 Knowledge of caretakers about treating 23

thrush

Figure 14 Knowledge of caretakers about two actions 24

should do regarding breast feeding

Figure 15 Knowledge of caretakers about sings that 24

would bring them immediately

Figure 16 Knowledge of caretakers about sings that 25

would bring them immediately( cough )

Figure 17 Knowledge of caretakers about sings that 25

would bring them immediately ( diarrhea )

Figure 18 Knowledge of caretakers about exclusive 26

breast feeding

Figure 19 Knowledge of caretakers about to which 26

age should breast feed the child

Figure 20 Knowledge of caretakers about 27

complementary feeding

Figure 21 Knowledge of caretakers about breast 27

feeding during child illness

Figure 22 Knowledge of caretakers about feeding and 28

fluid during child illness

Figure 23 Knowledge of caretakers about preparation 30

of ORS

Abstract:
Background : Integrated management of newborn and childhood illness
VII
(IMNCI) is a systematic approach to manage children’s common problem in
a holistic manner.Under-five child mortality rate in Sudan is high and
most of them die because of preventable causes that can be managed
probably at PHC level. The IMNCI strategy is composed of three
components that can contribute very much in reduction of child mortality
and morbidity if well implemented at PHC level. Our research is bound
to explore some of the strengths and weaknesses in the implementation of
the IMNCI strategy to identify the gaps that will assist local health
authorities in Shareg Elneel and the SMOH in improving the IMNCI
implementation.

Aim : The study aims at assessing the implementation of IMNCI

(SCM)of MD and MAs in PHC centers in sharg alneel locality in order to
identify gaps in implementation and propose possible solutions.

Result:
The doctor in alflah center not fully implementing the strategy,
majority of the mothers breastfeeds their children, with a percentage of
81.6% from the study population.,43.6% knew that children should be
breastfed until the age of two years, 46.8%, of mothers started
complimentary feeding for their children by the age of 6 months, (81.6%)
of mothers were exclusively breastfeeding their children in Sharg alneel
locality, Khartoum Sudan ,42.7% of the mothers increase the amount of
food during their children illness, majority of drugs and equipments are
not available .

Conclusion :
knowledge of mothers for children of both age groups (0-2)_(2-59)months
in an average level ,and this was affected by certain sociodemographic
factors such as level of education and family income , there is no
volunteers and educational visits in sharge alneel locality , the
feedback of caretakers about medical staff attitudes is satisfied , the
data not significant in occupation and nutritional state , there is
significant relationship between age and occupation and knowledge of
caretakers about preparation of ORS, significant relation between
education and knowledge about (0-2) month child , there I impressions
about staff is significant.

‫الملخص‬:

:‫المقدمه‬
‫اإلدارة المتكاملة ألمراض حديثي الوالدة واألطفال هي نهج منظم لصحة األطفال الذي‬
‫ة في‬k
k‫ن الخامس‬kk‫ال دون س‬k k‫األطف‬
VIII ‫ات‬k
k‫دل وفي‬kk‫ ومع‬، ‫يركز على رفاهية الطفل بأكمله‬
‫ معظمهم يموتون بسبب أسباب يمكن‬.‫ والدة حية‬1000 ‫ حالة وفاة لكل‬82 ‫السودان هو‬
‫ يمكن‬.‫الوقاية منها يمكن إدارتها على األرجح في مستوى الرعاية الصحية األولية‬
‫أن تقلل استراتيجية اإلدارة المتكاملة ألمراض حديثي الوالدة واألطفال من الكثير‬
، ‫من هذه الوفيات إذا تم تنفيذها بشكل جيد على مستوى الرعاية الصحية األولية‬
‫تراتيجية اإلدارة‬kk‫ذ اس‬kk‫وال بد أن يستكشف بحثنا بعض نقاط القوة والضعف في تنفي‬
‫حة‬k
k‫اعد الص‬kk‫تي ستس‬kk‫رات ال‬kk‫د الثغ‬k k‫د لتحدي‬k
k‫ال والموالي‬k
k‫المتكاملة ألمراض األطف‬
‫المحلية السلطات في شرق النيل ووزارة الصحة بالوالية في تحسين تنفيذ التدبير‬
‫المتكامل لصحة الطفل‪.‬‬

‫االهداف‪:‬‬
‫صفة عامة لتقييم تنفيذ استراتيجية التدبير المتكامل لصحة الطفل بما في ذل‪kk‬ك‬
‫‪k‬ة‬‫‪k‬ز الرعاي‪k‬‬ ‫‪k‬بين في مراك‪k‬‬ ‫‪k‬اعدين الط‪k‬‬‫‪k‬اء والمس‪k‬‬
‫‪k‬االت لالطب‪k‬‬
‫اإلدارة المعيارية للح‪k‬‬
‫الصحية األولية في منطقة شرق النيل من أجل تحديد الثغرات في التنفيذ واقتراح‬
‫‪k‬اء‬‫‪k‬بة من االطب‪k‬‬‫‪k‬د النس‪k‬‬
‫‪k‬و تحدي‪k‬‬‫‪k‬دد ه‪k‬‬
‫‪k‬دف المح‪k‬‬‫‪k‬ة ‪ ،‬في حين أن اله‪k‬‬ ‫الحلول الممكن‪k‬‬
‫والمساعدين الطبين الذين يتابعون مهارات الت‪kk‬دبير المتكام‪kk‬ل لص‪kk‬حة الطف‪kk‬ل ‪،‬‬
‫لتحديد العوامل التمكينية والمعطلة للنظام الصحي التي ق‪kk‬د ت‪kk‬ؤثر على تنفي‪kk‬ذ‬
‫التدبير المتكامل لصحة الطفل ‪ ،‬لتحديد نس‪kk‬بة مق‪kk‬دمي الرعاي‪kk‬ة ال‪kk‬ذين هم على‬
‫دراية بالممارسات العائلية والمجتمعية الرئيسية التي تتبناه‪kk‬ا وزارة الص‪kk‬حة‬
‫االتحادية‪.‬‬
‫النتائج‪:‬‬
‫الطبيبفي مركز الفالح لم ينفذ االستراتيجية بشكل كامل ‪ ،‬غالبية األمهات يرضعن‬
‫أطفالهن ‪ ،‬بنسبة ‪ ٪81.6‬من مجتمع الدراسة ‪ ٪43.6 ،‬علموا بضرورة إرضاع األطفال‬
‫حتى سن سنتين ‪ ٪46.8 ،‬منهم بدأت األمهات التغذية التكميلية ألطفالهن في سن ‪6‬‬
‫أشهر ‪ )٪81.6( ،‬من األمهات كن يرضعن أطفالهن رضاعة طبيعية حصرية في محلية‬
‫شرق النيل ‪ ،‬الخرطوم السودان ‪ ٪42.7 ،‬زيادة كمية الطعام أثناء مرض‬
‫أطفالهم ‪ ،‬غالبية األدوية والمعدات غير متوفرة‪.‬‬
‫الخالصهة‪:‬‬
‫ًا في‬
‫‪ -‬معرفة األمهات لألطفال من كال المجموعتين العمريتين (‪ )59-2( _ )2-0‬شهر‬
‫المستوى المتوسط ‪ ،‬وقد تأثر ذلك بعوامل اجتماعية ديموغرافية معينة مثل‬
‫مستوى التعليم ودخل األسرة ‪ ،‬وال يوجد متطوعين وزيارات تعليمية في منطقة‬
‫‪ ، Sharge alneel‬يتم استيفاء مالحظات القائمين على الرعاية حول مواقف الطاقم‬
‫الطبي ‪ ،‬والبيانات ليست مهمة في المهنة والحالة التغذوية ‪ ،‬هناك عالقة كبيرة‬
‫بين العمر والوظيفة ومعرفة مقدمي الرعاية حول تحضير أمالح اإلماهة الفموية ‪،‬‬
‫عالقة مهمة بين التعليم والمعرفة (‪ )2-0‬طفل في الشهر ‪ ،‬هناك انطباعات كبيرة‬
‫عن الموظفين‬

‫‪IX‬‬
CHAPTER ONE
1.Chapter 1: Introduction

1-1 Background:

The IMNCI is a systematic approach to improve children’s health. It

focuses on the well-being to the whole child. The IMNCI strategy
includes three main components: improving case management skills of
healthcare providers ,improving the health system support and improving
key family and community practices to ensure child’s health.
The IMNCI aims in general at reducing child’s death, frequency, and
severity of illness and disability, and it contributes to improved
growth and development of children under five years. [1]

Skills of health care providers (HCP)are improved through a training on

a standardized management protocol known as standard case management
(SCM).The training package of this strategy is meant to enable HCP at
PHC level to acquire the clinical and communication skills that will
help them pick and promptly manage under five sick children presenting
with common health problems.[1] The clinical guidelines are presented for
easy reference of HCP into chart-booklet and wall charts as well as
recording forms. The clinical guidelines covers two age groups of
children under five years: children aged 0- < 2 months and children aged
2-59 months.[2]
The guidelines are based on few simple, but evidence symptoms and signs
leading to classification of diseases rather than specific diagnosis
that requires diagnostic investigation. The guidelines are organized in
a systematic approach in a color coded formats that alert the HCP to the
severity of the child’s condition and it provides guidance to the
management plan including prescribing medicines, offering vaccination,
advising on treating diarrhea using ORS, treating local infections at
home etc…[3]
The SCM follow a sequenced step to properly and systematically manage
the child without the risk of missing symptoms or signs. It is
summarized as follows:
1. Assess and classify the child 2-59 months
2. Classify the child’s condition
3. Identify treatment
4. Treat the child
5. Counsel the mother
6. Follow up the sick child
1
7. Assess and classify the young infant 0-2 months
The second component “improving the health system support” is concerned
with organization of work and distribution of tasks at health
facilities, availability of medicines and supplies, referral of very
sick children, keeping records and monitoring and health information
[1]
systems, supervision, etc.

The third component ”improving key family practices” focuses on

dissemination and counseling care takers on a number of 12 global
evidence based practices recommended by WHO and UNICEF .[4]
Integrated management of childhood illness has been successfully
introduced in more than 75 countries around the globe. [1]

IMNCI Implementation in Sudan

The strategy has been introduced in Sudan as of 1996. By now, it was
introduced in XX % of health facilities and in 29 medical schools
within the in-service and pre-service training respectively.[5].
The training on SCM targets medical doctors (MD)for seven days and
medical assistants (MA) for 11 days. Other staff such as nurses,
vaccinators and nutrition educators perform some tasks of the SCM.
Examples are managing triage, taking temperature, providing vaccination
and growth monitoring services as well as counseling care takers
according to recommendations of HCP.[2]

Medicines and supplies required to facilitate SCM were included in the

national list of essential medicines and supplies and are distributed to
PHC centers as part of the policy of medicines.

As of 2001, the FMOH and partners adapted the 12 key family practices
(KFP) to nine for the implementation in Sudan based on regional surveys
that confirmed the gaps of knowledge and practice.[6]
These KFP are:
8. Early initiation of breastfeeding (BF)
9. Exclusive BF for six months
10. Complementary feeding at six months
11. Breastfeeding to 24 months
12. Home management of diarrhea
13. Care seeking
14. Sleeping under long lasting insecticide treated bed-
nets (LLITNs)
15. Safe disposal of child faeces and hand wash
16. Vaccination against common preventable diseases and
2
“Vit A” supplementation

The MOH and partners have introduced the KFP into all states training
community health volunteers (CHV) to disseminate the messages during
home visits using different educational material. Mother cards, flip
calendars and brochures were developed and disseminated. The CHV were
linked with the health facility and HCP were trained to supervise them.
Thus HCP are supposed to advise care takers and link the CHV in his
area for further communication.[7]

1-2 Problem statement:

The under-five child mortality rate in Sudan is high and is estimated at
82/ 1000 live births. Most of them die because of preventable causes
that can be managed probably at PHC level. Close follow up to SCM using
IMNCI strategy at PHC can reduce many of these deaths through early
detection of serious cases, provision of management and urgent
referral if needed .[7]
1-3 Rational:
We are not aware about a recent assessment of the implementation of the
IMNCI strategy in Sudan at PHC centers with focus on the SCM and health
system support. Our research is bound to explore some of the strengths
and weaknesses in the implementation of the IMNCI strategy . We think
atht it can inform the local health authorities in Shareg Elneel and
SMOH to improve the IMNCI implementation.
1-4 objectives
1-4-1 General objectives:
To assess the implementation of IMNCI strategy including adherence of
MD and MA to (SCM) in three PHC centers, in Sharg Alneel locality in
order to identify gaps in implementation and propose possible
solution.

1-4-2 Specific objectives:

1-To identify the proportion of MD and MAs who follow the IMNCI SCM
clinical guidelines.
2-To assess the health system support enabling and disabling factors
that might affect implementation of IMNCI.
3-To identify the proportion of care takers who are aware about the key
family and community practices adopted by FMOH

1-4-3 Variables:
1. Related to MD and MAs
a. Categories of HCP
b. Date of graduation
c. Working experience at PHC center in months (this one or before
this ) 3
d. Exposure to IMNCI in the pre-service training
e. Exposure to IMNCI in-service training
f. Following Tasks of SCM
 Asking about child complaint (mandatory for all children)
 Recording weight(mandatory)
  Recording temperature (mandatory)
 Asking and checking about general danger signs
(mandatory)
 Asking about the main symptoms (mandatory)

 Asking about cough or difficult breathing

 Asking about diarrhea
 Asking about fever
 Ear problem
 Checking nutritional status (mandatory)
 Checking vaccination and vit A supplementation
(mandatory)
 Asking and assessing about other problems (mandatory)

2-Related to care takers :

a) Categories of the care takers.
b) Categories of the children.
c) knowledge of care taker about how to deal with the child’s main
complaint. •
d) knowledge about the sever form of the disease which will bring them
back to facility. •
e) knowledge about nutrition and breastfeeding practices .
d) The caretaker satisfaction with performance of the HCP.
e) Existence of volunteers in neighborhood.
f) Existence of educational home visit.

4
CHAPTER TWO
2. Chapter Two: literature review

2-1 At global level:

A research was conducted in Mwanza, Tanzania, 2014 about factors
influencing the implementation of IMNCI by health care workers at public
health centers and dispensaries. The result of it ; are the main
challenges identified in the implementation of IMNCI are low initial
training coverage among the health care workers , lack of essential
drugs and supplies ,lack of onsite mentoring and lack of refresher
courses.[8]
Another study was done in west java province, Indonesia 2014 , about
challenges to the implementation of the IMNCI at community health
centers . It revealed that only 64% of adhered to SCM in managing all
visiting children.Several barriers to IMNCI implementation were
identified: including shortage of health workers trained in IMNCI , only
19% of health centers had all essential drugs and equipment for IMNCI .
[9]

A research done in India 2012 about IMNCI) skill assessment of health

and integrated child development scheme (ICDS) workers to classify sick
children under five years, 2014, the result of it ,all symptoms were
asked only in 15%. Danger sings were checked in <40% observations ,
immunization card was asked for in 20% observations. [10]

A study done in Uganda in June 2000 to assess the IMNCItrained health

providers counseling of care givers of children. Its results showed that
85% from the health providers performed well in assessing the child's
problems, 76% were giving feeding advice, 78% were giving advice on when
to return immediately, 75% for follow up and 97% for immunization.
Performance was considered poor in praising the caregivers with a
percentage of 43%. 65% asked feeding questions, 50% explained feeding
problems, 62% explained health problems, 44% gave advices on fluid
intake, and also 44% gave advice on using mother card.[11]
2-2 At Regional level:
A research done in Ethiopia 2019 to assess the factors affecting
the implementation of integrated management of childhood illness
treatment of under five children by health professionals in health care
facilities in yifat cluster
6 in north shewa zone , amhara region. The
result of it , revealed that proportion of IMNCI implementation in the
study setting was law (58%) . This study identified barriers by health
care workers which include : shortage of essential drugs and supplies ,
inadequate training staff , time consuming nature of protocol , lack of
supervision , lack of knowledge about strategy and lack of good
attitude of health care workers –professionals towered the IMNCI
[12]
strategy.

A research done in south Africa 2017 about health system factors

affecting implementation of integrated management of childhood illness
(IMCI):qualitative insights , the result of it ;key barriers for
implementation ;stock outs of growth monitoring equipment , vitamin A
and deworming drugs , generalized drug dispensing system , key enablers
promoting implementation ; using of standardized child health files with
IMNCI recording forms , availability of a national essential drug list .
[13]

A research done in Nekemte town Ethiopia about Knowledge , perception

and practice of mothers/caretakers and family’s regarding child
nutrition (under 5 years of age ),2013 ; the result of it about 84.2% of
mother practiced exclusive breastfeeding for the first 4-6 months
,highest proportions (92.4%) of women have knowledge that breastfeeding
should continue up to 2 years or older , 55.4% of mothers practiced
complementary food starting from 6 months.[14]

A research done in South Sudan 2017 about adherence to integrated

management of childhood illness guidelines in treating south Sudanese
children with cough or difficulty in breathing. The results showed that
83.2% from the participants asked about the child ability to drink or
breast-feed. 59.1% asked about convulsions, 52.6% asked about cough and
its duration, 66.0% looked for level of consciousness. 62.1% took off
the child's clothes and observed for abnormal breathing patterns, 65.1%
classified the presenting complaint correctly. Overall 9.9%:95%
respondents adhered to all the steps of IMNCI guidelines when treating
children with cough or DIB.[15]

2-3 At local level:

A research done in Sudan about knowledge, attitude and practice of
mother of under 5 years children regarding integrated management of
childhood illness in Salamat health center Omdurman Sudan 2016, the
result of which showed that , the mothers under study were found to
have several misconceptions regarding breast feeding (49%) were
exclusively breastfeed their last child, (82.3%) introduced
complementary feeding between 4-6 months , children who were immunized
up to date (93.4%) , (54%) of mothers using ORS .(42.4%) were increased
the amount of food during illness ,( 31.3%) stop breast feeding during
illness ,( 57.6%) of mothers
7 adhered to medical advice , (38.9%) of the
mother getting health information from the health workers .(16)

A research done in rufa, gezira state , sudan 2015 about; awareness of

mother of under five children towards home care of sick children in
malik alaagid health center ; the result of it was ;(61.0%)of
mothersdecrease fluid taken ,(79.5%) decrease food taken ,
(58.0%)decrease breast feeding , 80.5% of mother knew the meaning of
exclusive breast feeding , 71.5% of mothers used to start supplementary
feeding at 4-6 months , 88.5%of the children were fully vaccinated ,
9.5% partially vaccinated and 2%not vaccinated ,82% of mothers have
mother’s card , vitamin A supplementation was 60.5%.[17]

A research was done in Algenina west Darfur state in Sudan at 2014

aiming to evaluate the perception and practices on quality of IMNCI
among health care workers. It was interventional study design and data
was collected using structured questionnaire before and after
intervention. Health workers were tested twice to see the improvement of
their knowledge and performance. However the results of their knowledge
after the second test were as follow: 76% for assessment of children
main symptoms, 84.1% for classification of sever pneumonia and acute ear
infection, 77.1% for identifying treatment and immunization, and 90.1%
for their knowledge about urgent follow up. As the results were showing
noticeable improvement after intervention, the important study
recommendations are conducting regularly training to health workers and
refreshment courses, motivation, supervision and regular follow up.[18]

8
CHAPTER THREE
3.Chapter three: Method and materials

3-1 Study design:

This is an Observational descriptive cross sectional study.
The study focused on qualitative assessment of the strategy
implementation which included assessment of adherence of HCP to SCM
tasks, assessment of logistic supply at the PHC centers

3-2 Study population:

The study population included three categories: HCP managing children
under five years, care takers of sick children and facility support in
terms of services, equipment and supplies.
Inclusion criteria:
1/ HCP, those recommended by the health department at the locality as
being trained on IMNCI/SCM
2/ Care takers accompanying the child but is closely linked with and
aware about home care of the child.
Exclusion criteria:
Caretakerof a very sick child who requires urgent attention.

3-3 Study area:

Three primary health care centers in Sharg Elneel locality .The locality
is situated at the Eastern bank of the Nile and is one of seven locality
of Khartoum state. The locality is frequently exposed to floods and
therefore many of children fall sick during the rainy season (time of
data collection).
There is health affairs /department at the head of the locality which is
responsible of supervising PHC services. There are 46 PHC centers, only
six of them are referral centers where IMNCI should be implemented as
mentioned by health department.

9
3-4 Sampling design:
3.4.1 Sample size:
3-4-1-1- Sample size of care takers
During the design of our proposal in semester V111, we obtained the case
load in three PHC centers as follows:
Case load in the
S.N Health Center last
3 months
1 Alflah 350
2 Almaali 224
3 Almarabe 170

Total 744

Average monthly population in the three centers 744/3=248 child

We used the following formula to calculate the sample

NZ2 p (1-p)
n= d2 (N-1 )+ Z2 P( 1-p) where
n = sample size
N = Population Size
Z = statistic for a level of confidence
P = expectedproportion
d = precision
The values
N = 248 ( average monthly case load)
Z = 1.96
P = 0.5
d = 0.05
248×1.962× 0.5 (1-0.5)
n= 2 2
0.05 (248-1)+ 1.96 ×0.5(1-0.5)
Sub-total sample size was 152 sick child, adding 10% for non-
response the total sample was estimated at 167.2= 167 sick child
10
Our plan was to choose children from each center using stratified random
sampling according to the % of case load compared to the total (744);
however;as a result of the long suspension during the COVID 19
epidemic, and due to time limitation our supervisor advised us to take
all children we meet in the facility until we complete a sub-sample
according to the duration for data collection decided by the
supervisor. We managed to interview 121 care takers from the three
sites.
3-4-1-2- Sample size of HCP
Our proposal was to enroll all HCP (MD& MA) in the three centers.
However due to the same reason of COVID, we found only one HCP managing
sick children in one center (Al Falah)
3-4-1-3- Assessing health system support was conducted in the three
facilities

3-4-2 Sampling technique:

As we mentioned before due to limited time, we used a convent sampling
technique to enroll our study population, while total coverage was used
to access IMNCI supportive services provided in each facility.

3-5-Data management:
3-5-1-Data collection:
Assessment of the implementation of the IMNCI strategy is an extensive
process compared to time allowed for investigators.
The group was advised by the supervisor to take proxy indicators that
can confirm whether IMNCI protocol /strategy is implemented or not
regardless the quality level of doing the tasks under SCM.
1/ Health care providers (MD and MAs) observed while they are managing
under five children and a check list used by investigators to check
whether tasks of the SCM are followed or not. Some tasks fully
checked by observation such as “checking for chest indrawing”. So the
check list included only tasks that can be checked by observation only.
2/ Another check list used to assess available equipment and supplies
necessary to perform the SCM.
3/ A short structured interviewer administered questionnaire used to
collect data from care takers of children under five years

3-5-2-Data Analysis:
The responses were coded, and data was entered in the statistical
package of social science (SPSS), software version 19.0 and analyzed.
The percentage of various variables calculated and computed. Then the
result presented using text, charts, graphs, or tables.

3-6 Ethical considerations:

11
Research participants should not be subjected to harm in any ways
whatsoever. Respect of the dignity of the research participants
should be prioritized. Full consent should be obtained from the
participant prior to the study protection of the privacy of
research participants has to be insured. Adequate level of
 confidentiality of the research data should be insured.
Ananounimity of individuals and organizations participating in the
research has to be insured. Any deception or Exaggeration about the
aims of the objectives of the research must be avoided. Affiliation
in any forms, sources of findings, as well as any possible
conflicts of interests has to be declared. Any type of
communication in relation to the research should be done with
honesty and transparency. Any type of misleading information as
well as representation of primary data finding in a biased way must
be avoided.

3-7 Work plan:

Activity Time Month Date
Obtaining approvals Day1 February February
concerned institute of 2020
Training of data Day2 A February
collectors of 2020
Data collection Day4 August April of
2020
First draft of the Day5 October October
report of 2020
Amendments Day6 April of
2020
Submission of final Day7 October 15
report October
of 2020
Dissemination of Day8 June of
results 2020

12
CHAPTRE FOUR
4.Results:
The results presented here under are related to one health care
provider from alflah center/s and 121 care takers of children under five
years, collected during the period ( August-September ).

4-1-Health Care providers

4-1-1- Medical doctor from alflah center, Background information about
Health Care providers
4-1-2- performance of

Table 1: Health center staff medical treatment:

The result show that there is excellent medical treatment

Frequency Percent
Listened to her Yes 116 96.7
carefully No 4 3.3
Total 120 100.0

Frequency Percent
Examined child Yes 112 93.3
neatly No 8 6.7
Total 120 100.0

Frequency Percent
Explained Yes 115 95.8
management plan No Frequency5 Percent
4.2
Explained Yes Total 115
120 95.8
100.0
problem No 5 4.2
Total 120 100.0
12 Frequency Percent
Explained Yes 115 95.8
management plan No 5 4.2
Total 120 100.0
 Frequency Percent
she understood Yes 114 95.0
No 6 5.0
Total 120 100.0

Frequency Percent
follow Yes 114 95.0
up No 6 5.0
Total 120 100.0

Frequency Percent
Asked to come-back Yes 113 94.2
No 7 5.8
Total 120 100.0

Figure 1:
Presence of
13%
volunteers
in
13 Yes
neighborhood
No
:

87%
 Majority of result( 87%) show there is no neighborhood volunteers

Figure 2:Presence of educational home visits:

9%

Yes
No

91%

Majority of result(91%) show that there is no educational home visits

14
4-2- Children
4-2-1- Background information of children ( should be very short as it
is not related to HCP skill

Figure 3:Distribution of the children presenting to PHC centers

Sales

23% alfalah center Nearly half of

almaali center the children
marabe'e alshaeef center were at the
50%
alflah
center(50.0%).
28% The rest were
in almlee
(27.5%) and
marabe,e
alshareef
(22.5%)
15

Figure 4: Classification of children according to their gender:

 48% Male
52% Female

Almost half of the children were male(52%),and female (48%)

Figure 5: Distribution of child according to their age:

22%

0 to 2 months
2 to 59 months

78%

Majority of
child (78%) were at age of (2-59) months.

16

Figure 6: Child main complaint (0-2) months:

 17%
28%

Jaundice
Diarhhea
21% Nutrional problem
other

35%

Most of the children (34.5%) main complaint was diarrhea , (17.2%)

other complaint

17
Table 2: child main complaint (5-59) months:

Most of the children main complaint was diarrhea (39.4%), (2.1%)

complaint was nutritional problem

Frequency Percent
Main Not able to feed and 4 3.3
Complaint drink
2-59mo Lethargic or 7 5.8
unconscious
Cough or difficulty 11 9.2
breathing

Diarrhea 37 30.8
Has fever 17 14.2
ear problem 3 2.5
Nutritional problem 2 1.7

other problem 13 10.8

Total 94 78.3

18
4-3- Care takers
4-3-1- Background information of care takers
4-3-2- Knowledge and practices of care takers
4-4- Assessment of the health facility support

Figure 7: Distribution of caretakers by gender:

Sales

13%

Male
Female

88%

Females care takers represented 88%.

19
Figure 8: distribution of caretakers according to education:

Sales

18% 18%
None
Primary School
Secondary school
Higher

30% 33%

Most of caretakers ( 33.0%) were primary school level of education ,

followed by (30.0%) secondary school level

Education was found to be significant ( P value = 0.004 ) to their

knowledge about child (0-2) , and ( p value =0.085) knowledge of
caretakers about preparation of ORS

Education was found to be not significant ( p value = 0.728) to

receiving of child to exclusive breast feeding , and ( p value = 0.730)
to their knowledge about child (5-59) months

Table 3: Distribution of caretakers according to their age:

Most of caretakers( 28.3%) age (20-24) and (30-34) years, (0.8%) age
(45-49) and more than 50 years

Age of caretakers was found to be significant( p value = 0.146) to their

knowledge about preparation of ORS

20
 Frequency Percent
Age Less than 15yrs 3 2.5
in
15-19yrs 6 5.0
years
20-24yrs 34 28.3
of
the 25-29yrs 25 20.8
caretaker 30-34yrs 34 28.3
35-39yrs 5 4.2
40-44yrs 11 9.2
45-49yrs 1 .8
more than 50yrs 1 .8

Total 120 100.0

Figure 9: Distribution of caretakers according to their occupation:

Sales

14%
House wife
7% Professional employee
Laborer

79%
21
Majority of caretakers were house wife (79.9%),the rest were employee
(7%) and laborer (14%),
Occupation of caretakers was found to be not significant ( p value
=0.792) to receiving of child exclusive breast feeding, and ( p value
=0.605) to which aged child breast feed .

Figure 10: Distribution of caretakers according to their residency:

19%

35%
Majority of
Urban
Sub-Urban caretakers reside in
Rural sub-urban area (46%)
, the rest were
reside in urban
46%
(35%) and rural
(19%) area .

Figure
11:Distribution of caretakers according to their monthly income:

1%

28%

High
Average
22 Low

71%
 Majority of caretakers has average monthly income (71%), (28%) low
income ,( 1%) high income .

Figure 12 :Knowledge of caretakers about treating skin pustules or

umbilical infection:

8%
15%

knows
knows to some extent
does not know

77%

Most of caretakers (77%) know to some extent how to treat skin pustules
or umbilical infection, (15%) doesn’t no ,(8%) know

Figure 13:Knowledge of caretakers about treating thrush:

23
 15% 15%

knows
knows to some extent
does not know

69%

Majority of caretakers ( 69%) know to some extent how to treat thrush ,

(15%)doesn’t know , (16%) know

Figure 14: Knowledge of caretakers about the two actions should do

regarding breast feeding :

12%

knows
does not know

24
89%
 Majority of caretakers ( 88%) know the two actions.

Figure 15:Knowledge of caretakers about sings that would bring them

immediately with their child:

45% knows
does not know
55%

Majority of
caretakers
(55%) know the
sings.

Figure 16: Knowledge about sings that would bring them immediately with
their child (cough):

39%
knows Majority of
does not know the
61%
caretakers
25 (61%) know
the sings.
Figure 17: Knowledge of caretakers about sings that would bring them
immediately with their child(diarrhea):

34%

knows
does not know

66%

Majority of
the
caretakers
(66%) know
the sings

Figure 18: Knowledge of caretakers about exclusive breast feeding

Majority of
children
18%
received
exclusive
Yes
No breast
feeding
( 82%)
82%

Figure
19:Knowledge
of caretakers about to which age should breast feed the child :

26
 19%

37%
less than two years
Two years
More than two years

44%

Most of children (44%) received breast feeding for 2 years, (37%)

received breast feeding less than 2 years , (19%) received breast
feeding more than 2 years

Figure 20: Knowledge of caretakers about complementary feeding :

22%
31%

Less than 6 months

6 months
More than 6 months

47%

Most of children( 47%) received complementary feeding at the age of 6

month, (22%) 27
received complementary feeding at the age of less than 6
months , (31%) received complementary feeding at the age of more than 6
months
Figure 21: Knowledge of caretakers about breast feeding during child
illness :

7%

35%

She stops breast feeding

continues breastfeeding as before
increases breastfeeding
57%

Most of caretakers(57%) continues the breast feeding as before,

(36%)increase breast feeding ,(7%)stop breast feeding

Figure 22: Knowledge of Caretakers about feeding and fluid during child
illness

7%

43% She stops Fluid intake/feeding

continues Fluid intake/feeding as
before
increases Fluid intake/feeding
50%

28
 Most of caretakers(50%) continues fluid and feeding as before, (43%)
increase fluid and feeding , (7%) stop fluid and feeding

Figure 23: Knowledge of caretakers about preparing ORS :

37%
42% Knows how to prepare
knows to certain extent
has no idea

21%

29

Most of caretakers (42%) have no idea about preparation of ORS, (37%)

know how to prepare , (21%) know to certain extent
4-4- Assessment of the health facility support

Majority of the equipments are not available in the primary health

centers ( 66.7%), only (thermometer , microscope, disposal and insulin
syringes are available in all the three health centers (100%))

Majority of the drugs not available in the primary health centers

Only few amount of drugs available in all the centers ( zinc ,

pararcetamol, ciprofloxacin , erythromycin ( 100%))

Majority of vaccines available in the primary health centers (66.7%)

Table 4: Availability of equipment :

IMCI case recording form Availability and Functioning.

Frequency Percent
Available 1 33.3
not available 2 66.7

Total 3 100.0
Mothers card Availability and Functioning
30
Available 1 33.3
not available 2 66.7
Total 3 100.0
Referral slip Availability and Functioning.
IMCI case recording form Availability and Functioning.
Frequency Percent
Available 1 33.3
not available 2 66.7

Available 1 33.3
not available 2 66.7
Total 3 100.0
Chart booklet Availability and Functionig
not available 3 100.0
ARI timer Availability and Functioning.
Available 2 66.7
not available 1 33.3
Total 3 100.0
Thermometer Availability and Functioning.
Available 3 100.0
Weight machine Availability and Functioning.
Available 3 100.0
Nebulizer Machine Availability and Functioning.
Available 2 66.7
not available 1 33.3
Total 3 100.0
Spacer Availability and Functioning.
Available 2 66.7
not available 1 33.3
Total 3 100.0

Microscope for malaria test Availability and Functioning.

Frequency Percent
Available 3 100.0
RDT strips and reagent for malaria Availability and Functioning.
Available 3 100.0
BP Cuff for Tourniquet test Availability and Functioning.
Available 1 33.3
not available 2 66.7
Total 31 3 100.0
IMCI reporting format (HMIS) Availability and Functioning.
Available 1 33.3
not available 2 66.7
Total 3 100.0
 Microscope for malaria test Availability and Functioning.
Frequency Percent
Available 3 100.0
Suction Machine Availability and Functioning.
Not Available 3 100.0
NG tube Availability and Functioning.
Available 1 33.3
not available 2 66.7
Total 3 100.0
Cup, Spoons for ORT Availability and Functioning.
Available 1 33.3
not available 2 66.7
Total 3 100.0
Disposable Syringes Availability and Functioning.
Available 3 100.0
Insulin Syringes Availability and Functioning
Available 3 100.0
Absorbent clean cloth/ soft but strong tissue for ear wicking
Availability and Functioning.
Available 1 33.3
not available 2 66.7
Total 3 100.0
RUFT Availability and Enough Stock.
Not Available 3 100.0

Table 5: Availability of drugs :

32
Capsule Vitamin A (50000 i.u.) Availability and Enough Stock.

Frequency Percent
Available 2 66.7
Not Available 1 33.3

Total 3 100.0
Capsule Vitamin A (200000 i.u.) Availability and Enough Stock.
Not Available 3 100.0
Tab. Ciprofloxacin (250mg) Availability and Enough Stock.
Available 3 100.0
Tab. Ciprofloxacin (500mg) Availability and Enough Stock.
Available 3 100.0
Tab. tetracycline 250mg Availability and Enough Stock.
Available 3 100.0
Tab. Amoxicillin250mg Availability and Enough Stock
Available 2 66.7
Not Available 1 33.3
Total 3 100.0
Tab. Amoxicillin500 mg Availability and Enough Stock
Available 1 33.3
Not Available 2 66.7
Total 3 100.0
Tab. Erythromycin (250mg) Availability and Enough Stock.
Available 3 100.0
Syrup. Erythromycin Availability and Enough Stock.
Not Available 3 100.0
Tab. Quinine (300mg) Availability and Enough Stock.
Not Available 3 100.0

33
Inj. Quinine (300mg/2ml) Availability and Enough Stock.
Frequency Percent
Available 1 33.3
not available 2 66.7
Total 3 100.0
Tab. Arthemeter (20mg) +lumefantrine (120mg) Availability and
Enough Stock.
Available 1 33.3
not available 2 66.7
Total 3 100.0
Inj Diazepam 10 mg/2ml Availability and Enough Stock.
Available 2 66.7
not available 1 33.3
Total 3 100.0
Syrp.Zinc10 Availability and Enough Stock.
Available 3 100.0
Tab.Zinc Availability and Enough Stock.
Available 2 66.7
not available 1 33.3
Total 3 100.0
Tab. Tetracycline Availability and Enough Stock.
Not Available 3 100.0
Tab. Paracetamol 500mg Availability and Enough Stock.
Available 3 100.0
Syrup. Paracetamol 125 Availability and Enough Stock.
Available 2 66.7
not available 1 33.3
Total 3 100.0
Inhaler Paracetamol (100mcg) Availability and Enough Stock.
Available 1 33.3
Not Available 2 66.7
Total 3 100.0

Syrup. Salbutamol Availability and Enough Stock

Frequency Percent
Available 34 3 100.0
Tab Salbutamol Availability and Enough Stock.
Not Available 3 100.0
IV fluid: Ringer lactate Solution Availability and Enough Stock..
Available 1 33.3
Syrup. Salbutamol Availability and Enough Stock
Frequency Percent
Available 3 100.0
not available 2 66.7
Total 3 100.0
IV fluid: 9% Normal Saline Availability and Enough Stock.
Available 2 66.7
not available 1 33.3
Total 3 100.0
Tab. Ferrous sulfate (200mg) +folate (250mg) Availability and
Enough Stock.
Available 1 33.3
Not Available 2 66.7
Total 3 100.0
Syrup. Ferrous fromate (100mg) Availability and Enough Stock.
Not Available 3 100.0
Dihydroartthin+pepracain Availability and Enough Stock
Not Available 3 100.0
Pricemon Availability and Enough Stock.
Not Available 3 100.0
Tab.Ampicillin (500mg) Availability and Enough Stock.
Available 2 66.7
Not Available 1 33.3
Total 3 100.0
Tab.Ampicillin (250mg) Availability and Enough Stock.
Not Available 3 100.0
Syrp.Ampicillin (250mg) Availability and Enough Stock.
Not Available 3 100.0

Gentamycin (80mg) Availability and Enough Stock.

Frequency Percent
Available 1 33.3
Not Available 2 66.7

Total 3 100.0
ORT Availability and Enough Stock.
35
Available 1 33.3
Not Available 2 66.7
Total 3 100.0
Injection Artesunate Availability and Enough Stock.
Not Available 3 100.0
 Gentamycin (80mg) Availability and Enough Stock.
Frequency Percent
Available 1 33.3
Not Available 2 66.7

Tetracycline eye ointment Availability and Enough Stock.

Available 3 100.0

Table :Availability of the vaccinations:

BCG
Available 3 100.0
OPV0
Available 2 66.7
not available 1 33.3
Total 3 100.0
OPV1
Available 2 66.7
not available 1 33.3
Total 3 100.0
OPV2
Available 2 66.7
not available 1 33.3
Total 3 100.0

OPV3
Frequency Percent
Available 36 2 66.7
Not Available 1 33.3

Total 3 100.0
DPT
OPV3
Frequency Percent
Available 2 66.7
Not Available 1 33.3

Available 2 66.7
Not Available 1 33.3
Total 3 100.0
HIB
Available 2 66.7
Not Available 1 33.3
Total 3 100.0
Total 3 100.0
Hep
Available 2 66.7
Not Available 1 33.3
Total 3 100.0
RTV1
Available 2 66.7
Not Available 1 33.3
Total 3 100.0
RTV2
Available 2 66.7
Not Available 1 33.3
Total 3 100.0

PCV1
Frequency Percent
Available 2 66.7
Not Available 1 33.3

Total 3 100.0
PCV2
Available 2 66.7
Not Available 1 33.3
Total 3 100.0
PCV3
37
Available 2 66.7
Not Available 1 33.3
Total 3 100.0
Penta Vaccine
Available 2 66.7
PCV1
Frequency Percent
Available 2 66.7
Not Available 1 33.3

not available 1 33.3

Total 3 100.0
Measles Vaccine
Available 3 100.0
Meningitis vaccine
Available 3 100.0
IPV
Available 2 66.7
Not Available 1 33.3
Total 3 100.0

38
CHAPTER FIVE
Dissection:
This result was designed to identify the assessment of the
implementation of imnci strategy in three primary health centres, in
sharg alneel locality, Khartoum.
The result showed that : majority of the mothers breastfeeds their
children, with a percentage of 81.6% from the study population. This is
in line with a similar study done in Ethiopia (2013) in which found that
majority of the mothers breastfeeds their children for the first 4-6
months with a percentage of 84.2% from the study population.
43.6% of our study population knew that children should be breastfed
until the age of two years, compared to a study conducted in Ethiopia
(2013) where which 92.4% of the mothers answered that the child
breastfeeding should continues up to 2 years or older.
The majority of mothers started complimentary feeding for their children
by the age of 6 months with a percentage of 46.8%, this result was
almost the same as the result of the study done in Ethiopia where 55.4%
of mothers started practicing complimentary feeding for their children
by the age of 6 months.
On the national level, the results showed that mothers were exclusively
breastfeeding their children in study done in Umdurman state, Sudan
(2016) with a percentage of 49%.
While in a study done at Algazira state, Sudan(2015) the percentage was
8.5% only .
On the other hand, our study showed that majority of mothers were
exclusively breastfeeding their children in Sharg alneel locality,
Khartoum Sudan (81.6%).
42.7% of the mothers in our study show that they increase the amount of
food during their children illness, almost the same percent showed at
the study conducted at Umdurman state, Sudan(2016) which was 42.4%.

Conclusion:
In conclusion our study showed that the knowledge of mothers for
children of both age groups (0-2)_(2-59)months in an average level ,and
this was affected by certain sociodemographic factors such as level of
education and family income , the health institution did not provide
volunteers in sharge alneel locality m there for we concluded that
enhancing this method of providing information can greatly increase the
knowledge of mothers , the40 feedback of caretakers about medical staff
attitudes is satisfied , the data not significant in occupation and
nutritional state , there is significant relationship between age and
occupation and knowledge of caretakers about preparation of ORS,
significant relation between education and knowledge about (0-2) month
child , there I impressions about staff is significant.
Recommendation:
1- The health center should contain more than one doctor implement
IMNCI strategy.
2-there should be periodic refresher IMNCI course .
3-The equipment and drugs should be more available .
4-The institution should provide a good source of information for
caretakers by educational visits

Limitation:
Unfortunately, the doctors implementing the IMNCI strategy in two
centers were not present at the health centers that have been chosen
for the research by the time of data collection , and that was due to
covid-19 pandemic and other personal matter as well. Doctors we found
were all not implementing the strategy.

41
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[4] WHO/UNICEF: improving family and community practice ,a component of

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[12]Ayele Mamo Abebe m Mesfin Wudu kassaw and Fikir Alebachew

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[14] Wondu garoma berra , Knowledge , perception and practice of

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[15] Adherence to Integrated Management of Childhood Illnesses Guideline

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[17]Rehab imam mukhtar elsharief

43 , awareness of mother of under five
towards home care of sick children, 12/2015 .corpus d 150561945.
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http://repository.ush.sd:8080/xmlui/handle/123456789/421

44
Annexes :
Annexes 1: research questionnaire :
Nile university
MBBS program
Community medicine department

Exit interview:

Date: / /2020Time:
Name of the PHC center: _____________________
Name of the data collector: ___________________

 Personal data of the caretaker:

1. Gender :
- Male ( ) - Female ( )
2. Education:
- None ( ) - primary( )
- secondary ( ) - higher ( )
3. Age in years:
- less than 15yrs ( ) - 15-19yrs( )
- 20-24yrs ( ) - 25-29yrs( )
- 30-34yrs ( ) - 35-39yrs( )
- 40-44yrs ( ) -45-49yrs ( )
- more than 50yrs ( )
4. Occupation of the caretaker: ___________________________
- House wife ( )
- Professional employee ( )
- Laborer ( )
5. Residence of the caretaker :
- Urban ( )
- Sub-Urban ( )
- Rural ( )
6. Family monthly income as perceived by caretaker :
- High ( )
- Average ( )
- Low ( )
 Personal data of the child:
7. Age: 45
- 0 to 2 months ( )
- 2 months to 59 months ( )
 8. Gender:
Male ( )
Female ( )

 For 0-2 months:

9. What was the main complaint of the baby?
-convulsions ( )
-Jaundice ( )
-diarrhea ( )
-Nutritional problem ( )
-Other ( )
-mention it: ____________________.

Ifthe child has severe classification as per the chart booklet do

not conduct the interview
10.If the infant has local bacterial infection:
a.Treat skin pustules or umbilical infection:
1. Wash hands ( )
2. Wash off pus or pustules ( )
3. Dry the area ( )
4. Paint with gentian violet ( )
5. Wash hands ( )

Knows ( ) Know to some extent( ) Does not know ( )

b.Treat thrush:
1. Wash hands ( )
2.Wash mouth with clean soft cloth wrapped around the
finger and wet with salt water ( )
3.Paint the mouth with half-strength gentian
violet ( )
4. Wash hands ( )

Knows ( ) Know to some extend( ) Dose not know ( )

c.Home Care :What are 46 the two actions that you should do
regarding breastfeeding ?
1.Increase breastfeeding and fluids ( )
2.Feed by cup ( )
3.keep the low weight infant warm ( )
 Knows ( ) Dose not know ( )
11.What are the signs which will bring you back immediately with
your baby?
- Does not suckle or drink naturally ( )
- Deterioration ( )
- Less movement ( )
- Develops fever or decrease in body temperature( )
- Difficulty in breathing ( )
- Jaundice extend to palms or soles of feet’s ( )

 For children 2-59 months :

12.What was the main complaint of the baby?
- Convulsions ( )
- Not able to feed and drink ( )
- Lethargic or unconscious ( )
- Cough or difficulty breathing ( )

- Diarrhea ( )
- Has fever. ( )
- Ear problem ( ) -
Nutritional problem ( )
-Other ( ) mention
it: ______________________

13.What are the signs which will bring you immediately back with
baby ?
Signs for any child:
- Not able to feed ( )
- Becomes sicker ( )
- Developed fever ( )

Knows ( ) Does not know ( )

Cough :
- Faster breathing ( )
- Difficulty in breathing ( )

Knows ( ) Dose not know ( )

Diarrhea:
- Blood in stool ( )
- Drinking poorly ( )

Knows ( ) Dose not know ( )

47
14.how do you feed your child in illness
-Increase breast feeding ( )
-Increase fluids ( )

Knows ( ) Dose not know ( )

15.Did he receive exclusive breastfeeding?
- Yes ( )
- No ( )
why: _________________________.
16.Till what age was the child breastfed?
- less than two years ( )
- Two years ( )
- More than years ( )

17.At what age did you start complimentary feeding?

- Less than 6 months ( )
- 6 months. ( )
- more than 6 months ( )
18.Regarding breastfeeding during the child illness :
- She stops breast feeding ( )
- continues breastfeeding as before ( )
- increases breastfeeding ( )
19.Regarding Fluid intake and feeding during the child illness :
- She stops Fluid intake/feeding ( )
- continues Fluid intake/feeding as before ( )
- increases Fluid intake/feeding ( )
20.How do you prepare the ORS for the child?
- knows how to prepare ( )
- knows to certain extent. ( )
- has no idea ( )

 Questions for both age groups:

21.What does the caretaker think of the medical staff attitude?

- Listened to her carefully ( )
- Examined the child neatly ( )
- Explained the problem for her ( )
- Explained the management plan in details ( )
- He made sure that she understood ( )
- He gave her time for follow up ( )
- He asked her to come back in case of any problem occurred
( )
-if the child got sick again , well she come back for the same
medical staff ( )
22.Is there any volunteers in the neighborhood?
- Yes ( )
- No 48 ( )
23.Is there anyeducational home visits run by volunteers?
- Yes ( )
 - No ( )

Note:
Preparation: 6 teaspoons of sugar, half a teaspoon of salt, and
1liter of water
Mix salt and sugar well in water then put the solution in a
clean bottle wait till cool and ready to drink.

Annexes 2: check list 1

check list to assess standard case management

skills of doctors and medical assistances’

Name of thehealthcentre:………………………………….. Date

ofsupervision:......../......../........
Did provider follow IMCI
NO protocol during case Yes No Not applicable
management

Assess and classify sick child age 2 months up to 5 years

Ask if this an initial or

1
follow up visit ?
If follow up visit did
provider use the follow up
2
instructions on treat the
child chart?

Ask about General danger signs and other signs?

3
Is the child able to drink or
3.1
breastfeed?
Dose the child vomit every
3.2
things?
3 Has the child had
.3 convulsions ?
See if the child is49lethargic
3.4
or unconscious ?

3.5 Is the child convulsing now ?

 Providing valium to convulsing
3.6
child

3.7 Use recording form ?

4 Ask about major sings

Ask if the child have cough

4.1
or difficulty in breathing ?
4.1
Count the breath?
.1
4.1
Look for chest in drawing ?
.2
4.1
Look and listen for strider?
.3
4.1 Look and listen for
.4 wheezing ?
4.1
Use recording form ?
.5
4. Ask if the child have
2 diarrhea?
4.2
Ask for how long?
.1
4.2
Ask about blood in stool ?
.2
4.2 Look and feel lethargic or
.3 unconscious ?
4.2
Look for sunken eye?
.4
4.2
Offer the child fluid ?
.5
4.2 Did provider do skin pinch
.6 of the abdomen ?
4.2
Use recording form ?
.7
4.2 Look and feel Restless or
.8 irritable?
4.
Ask if the child have
50 fever?
3
4.3
Asked for how long?
.1
4.3 Asked if the fever present for
.2 7 days or daily?
Asked if the child have
4.3
measles or within the last 3
.3
month? If yes
4.3
Look for mouth ulcer?
.4
4.3 Look for pus draining from the
.5 eye ?
4.3 Look for clouding of the
.6 cornea?
4.3
Look for other causes ?
.7
4.3
Use recording form ?
.8
Ask if the child have ear
4.4
problem ?
4.4
Ask about ear pain ?
.1
Ask if their ear discharge ?if
4.4
yes
.2

4.4
Ask for How long?
.3
4.4 Look for pus draining from the
.4 ear ?
4.4 Feel tender swelling behind
.5 the ear ?
4.4
Use recording form ?
.6

Check for acute manlnutrition

5
5
Look for edema of both feet ?
.1

5.2 Measure weight ?

5.3 Determine WFH/LP__z score ?

51
Measure MUAC _mm in child
5.4
6monthes or older?

5.5 Did provider use growth chart?

 Did provider use recording
5.6
form?

Check for anemia

6

6.1 Look for palmer pallor?

Check for child immunization

6.2 and give him preventive
vitamin A dose?
6
Assess other problem?
.3
6
Give treatment ?
.4
Explain to mother how to give
6.5
oral drugs at home ?

6.6 Counsel the mother ?

6.7 Give follow up ?

6.8 Use mother card ?

Assessing ,classify and treat sick young infant age up to 2

1
month

1.1 Ask about child problem ?

Ask is it initial visit or

1.2
fllow up ?
Follow the instructions in
1.3
the follow up visit?
Check for very sever disease
2
and local bacterial infection?
Ask if the infant have
2.1
convulsions ?
Ask if he infant having
2.2
difficulty in feeding ?
Count the breath in case of
2.3
convulsion ?
Measure the 52 axillary
2.4
temperature ?
Look at the umbilicus is it
2.5
red or draining pus ?
2.6 Look for skin pustules ?

Ask mother to wake infant if

2.7
the infant sleeping ?
Look for the movement of the
2.8
infant ?

3 Check for jaundice

Ask if the jaundice start in

3.1
the first 24 hour ?

3.2 Check infant weight ?

Look at the young infant

3.3
palms and soles ?

3.4 Use recording form

Ask if the young infant have

4
diarrhoea ? if yes

4.1 Ask for how long ?

Look at the young infant

4.2
general condition ?

4.3 Look for the infant movements?

4.4 Look for the shunken eye ?

Pinch the skin of the

4.5
abdomen ?

4.6 Use recording form?

5 Check for feeding problem or low weight

Ask if the infant breast

5.1
feed? if yes
Ask how many time in 24 hours
5.2
?
Ask dose the infant usually
5.3 receive any other 53foods or
drinks ? if yes

5.4 Ask how many times in day ?

 Ask what do you use to feed
5.5
the infant ?
Ask what milk are you
5.6
giving ?
Ask how many times during
5.7
the day and night ?
Ask how much us given at each
5.8
feed ?
Ask how are you preparing the
5.9
milk ?
5.1
Let mother explain ?
0
5.1 Ask are you giving any breast
1 milk at all ?
Ask what foods and fluids in
5.1
addition to replacement feeds
2
is given ?
5.1 Ask how is the milk being
3 given ?
5.1
Ask cup or bottle ?
4
5.1 Ask how are you cleaning the
5 feeding utensils ?
5.1
Determine weight for age ?
6
5.1 Look for ulcers or white
7 patches in the mouth ?
5.1
Use recording form ?
8

6 Check for young infant immunization

6.1 Give missed doses on visit ?

Advise the caregiver when to

6.2
return for the next dose?

7 Assess other problem ?

Did HCP identified 54treatment

8
using the chart booklet ?
Did HCP counseled care taker
9 about the medication he
prescribed ?
Annexes 3: Checklist

Check List to Assess Health System Equipment and Supply

Name of the Health Centre:…………………………………………

Date:………………………..

Logistics Available Functioning

IMCI case recording

form
Mother’s card

Referral slip

Chart booklet

ARI timer(functioning)

Thermometer

Weight machine

Nebulizer Machine

Spacer
Microscope for malaria
test
RDT strips and reagent
for malaria
BP Cuff for Tourniquet
test
IMCI reporting format
(HMIS)
Suction Machine

NG tube

Cup, Spoons for ORT

55
Disposable Syringes

InsulinSyringes
Absorbent clean cloth/
soft but strong
 tissue for ear wicking

Annexes 4: Checklist 3

56
Medicine Available Adequate enough
in stock for one
month
Capsule Vitamin A ( 50000 i.u.)
Capsule Vitamin A ( 200000 i.u.)
Tab.Ciprofloxacin(250mg)
Tab.Ciprofloxacin(500mg)
Tab.Tetracyclin(250mg)
Tab. Amoxicillin(250mg)
Syrp. Amoxicillin(125mg)
Tab. Ciprofloxacin (500mg)
Tab. Ciprofloxacin (250mg)
Tab. Erythromicyn(250mg)
Syrp. Erythromicyn
Tab. Quinine (300mg)
Inj. Quinine ( 300mg/2ml)
Tab. Arthemeter(20mg)
+lumefantrine(120mg)
Inj Diazepam 10 mg/2ml
Syrp,zinc(10mg)
Tab.Zinc(20mg)
Tab.Tetracycline (250mg)
Tab. Paracetamol( 500mg)
Syrp. Paracetamol( 125mg)
Inhalar paracetamol(100mcg)
Syrp. Salbutamol
Tab.Salbutamol
IV fluid: Ringer lactate
IV fluid: 9% Normal Saline
Tab. Ferrous sulfate (200mg)+folate
(250mg)
Syrp. Ferrous fromate (100mg)
Dihydroartthin+pepracain
Pricemon
Tab.Ampicillin (500mg)
Tab.Ampicllin(250mg)
Syrp.Ampicllin(250mg)
Gentamycin (80mg)
ORT
Salbutamol 57

Inj.Artsunate
Tetracyclin eye ointment
RUFT
Annexes 5:checklist 3

Vaccine Available Unavailable

BCG
OPV0
OPV1
OPV2
OPV3
DPT
HIB
Hep
RTV1
RTV2
PCV1
PCV2
PCV3
Penta Vaccine
Measles Vaccine
Meningitis vaccine
IPV

Annexes 6: Informed consent:

We, the investigators , Reham Hamad Muhammad Othman, al-Malik, Abu Bakr
Mahmoud Muhammad Ali, Akram Abd al-Rahman Ahmad Othman, Muhammad Hashem,
Alaa Yusuf Dafa Allah Muhammad, fifth-year medicine students, Nile
University, are conducting a study on the evaluation of the
implementation of the integrated treatment strategy for childhood
diseases adopted by the Ministry of Health. The first objective of this
study is to apply scientific research methods as we studied, and the
second is to learn the application of the strategy of integrated
treatment for childhood diseases adopted by the Ministry of Health.
. You have been selected to participate in this research and with you 20
other respondents to collect
58 information on assessing the implementation
of the strategy by doctors and paramedics. We expect, with your
participation and other participants, to obtain results that benefit the
community and provide sufficient and accurate information on the method
of implementing the strategy During this study, I will take information
from you and fill out a form clarifying personal information about you.
‫‪We will also use the control list to obtain some important information‬‬
‫‪for our study. This information will be kept in a confidential way‬‬
‫‪without writing your name on the form. We would like to point out to you‬‬
‫‪that participation in the research is completely voluntary, and with‬‬
‫‪your participation you will be one of the volunteers included in the‬‬
‫‪research, whose number is a volunteer from the doctors, as we can assure‬‬
‫‪you.‬‬
‫‪You have complete freedom to participate, or not, or not to answer the‬‬
‫‪question that you think is unacceptable to you.‬‬
‫‪If you have any question about research , the participant with you in‬‬
‫‪the research , or your rights as a participant during the research m you‬‬
‫‪can contact :‬‬

‫‪+249900252936‬‬
‫‪+249961574665‬‬
‫‪+249907455723‬‬

‫المرفقات ‪ :5‬الموافقة المسبقة‪:‬‬

‫نحن المحققين ريهام حمد محمد عثمان ‪ ،‬المالك ‪ ،‬أبو بكر محمود محمد علي ‪،‬‬
‫أكرم عبد الرحمن أحمد عثمان ‪ ،‬محمد هاشم ‪ ،‬عالء يوسف دفع هللا محمد ‪ ،‬السنة‬
‫الخامسة طالب الطب جامعة النيل ‪ ،‬نقوم بدراسة‪ .‬بشأن تقييم تنفيذ استراتيجية‬
‫العالج المتكامل ألمراض الطفولة التي اعتمدتها وزارة الصحة‪ .‬الهدف األول من‬
‫هذه الدراسة هو تطبيق أساليب البحث العلمي كما درسنا ‪ ،‬والثاني معرفة تطبيق‬
‫استراتيجية العالج المتكامل ألمراض الطفولة التي تتبناها وزارة الصحة‪.‬‬
‫ًا آخر لجمع معلومات‬ ‫‪ .‬لقد تم اختيارك للمشاركة في هذا البحث ومعك ‪ 20‬مستجيب‬
‫حول تقييم تنفيذ االستراتيجية من قبل األطباء والمسعفين‪ .‬نتوقع ‪ ،‬بمشاركتك‬
‫والمشاركين اآلخرين ‪ ،‬الحصول على نتائج تفيد المجتمع وتوفر معلومات كافية‬
‫ودقيقة حول طريقة تنفيذ اإلستراتيجية خالل هذه الدراسة ‪ ،‬سأأخذ معلومات منك‬
‫ًا قائمة التحكم‬ ‫وأمأل استمارة توضح المعلومات الشخصية عنك ‪ .‬سنستخدم أيض‬
‫للحصول على بعض المعلومات المهمة لدراستنا‪ .‬سيتم االحتفاظ بهذه المعلومات‬
‫بطريقة سرية دون كتابة اسمك في النموذج‪ .‬نود أن نوضح لك أن المشاركة في‬
‫ما ‪ ،‬وبمشاركتك ستكون أحد المتطوعين المشمولين في البحث ‪،‬‬ ‫البحث تطوعية تماً‬
‫وعددهم متطوع من األطباء ‪ ،‬كما يمكننا أن نؤكد لكم‪.‬‬
‫لديك الحرية الكاملة في المشاركة ‪ ،‬أو عدم المشاركة ‪ ،‬أو عدم اإلجابة على‬
‫السؤال الذي تعتقد أنه غير مقبول بالنسبة لك‪.‬‬
‫إذا كان لديك أي سؤال حول البحث ‪ ،‬أو المشارك معك في البحث ‪ ،‬أو حقوقك‬
‫كمشارك أثناء البحث ‪ ،‬يمكنك االتصال بـ‪:‬‬

‫‪249900252936+‬‬
‫‪249961574665+‬‬
‫‪249907455723+‬‬

‫‪59‬‬