1. Barriers to implementation of HIV guidelines in the IMCI algorithm among IMCI-trained health workers in Zambia (a cross sectional survey) Authors:  Nanthalile Mugala, MD, Abt Associates, Inc., Health Services and Systems Project: Facility IMCI Advisor  Wilbroad Mutale, MD, Univeristy of Zambia, Lecturer  Penny Kalesha, MD,Zambia Ministry of Health, Child Health Specialist  Elijah Sinyinza, MD, MPH, Abt Associates, Inc., Health Services and Systems Project, Deputy Chief of Party

2. Health Services and Systems Program (HSSP) A USAID-funded project implemented by Abt Associates Inc., in partnership with: JHPIEGO, ISTI, and Save the Children Provides technical assistance to the Zambian Ministry of Health across a number of technical areas: Child Health and Nutrition Integrated Reproductive Health Malaria HIV/AIDS Health Systems

3. Introduction Zambia’s HIV prevalence among 15-49 years 14.3% (ZDHS 2007) IMCI strategy first introduced in 1995 Over 3000 (cumulative) health workers trained to date IMCI algorithm adapted in 2004 to include HIV guidelines Entry point to the health system for any sick child to access HIV/ART services Provides opportunities for linkages with other important HIV related programs such as PMTCT

4. Study Justification IMCI post-training follow-up visits conducted March 2007 and January 2008 97% (87 of 90) of the health workers assessed did not review or mention the HIV guidelines Findings of non-adherence to HIV guidelines implied that children in need of HIV services may be missing access to care and treatment

5. Study Objectives General Objective: To explore the barriers to implementation of the HIV guidelines within the IMCI algorithm Specific Objectives: To study the level of adherence to the guidelines To establish the policy implications of health workers’ adherence to the guidelines To determine the factors associated with adherence to the HIV guidelines in the IMCI algorithm To make recommendations on how adherence to guidelines can be improved

6. Methodology Multi-stage sampling Employed convenience sampling of 8 districts Random sampling for individuals Data collection method 29 Individual questionnaires 8 key informant interviews 7 Focus group discussions Data analysis Quantitative data analyzed using STATA Qualitative data analyzed using open-code software for qualitative data (Umea University, Sweden)

7. Demographic Characteristics

10. IMCI /HIV adherence and associated factors 90% recalled having been trained in HIV guidelines; 18/29 (62%) through the standard training and 8/29 (28%) through peer orientation 26/29 (90%) recalled having received initial follow-up visits 24/29 (83%) had no difficulties following the IMCI algorithm and 5/29 (17%) had difficulties Of the 5 reporting difficulties, 3 (60%) cited HIV assessment as the area where they had difficulties

11. IMCI /HIV adherence and associated factors: conditions which could prompt health worker to enter the HIV box Persistent diarrhea66% Pneumonia66% Growth faltering or low weight for age 83% Chronic ear infection28% Others68%

12. IMCI /HIV adherence and associated factors: Why the respondent or other health workers may not adhere to HIV guidelines Pre-determined factors% Shortage of staff79% oversight48% Stigma of staff towards HIV17% Stigma in the community66% Inadequate training55% Guidelines not user friendly7%

13. Sample responses from Key Informants/Focus Group Discussions Q: Any problems following the IMCI algorithm? “No problems” reported 17 times Q: What do you think about HIV assessment? “its ‘ok’; when you use it frequently some things will stick.” “Time” was mentioned 14 times during the discussions: “Due to pressure of work and shortage of staff, it is difficult to spend a long time on each child” “The chart booklets are time consuming and if you keep on referring to it, you will be viewed as being incompetent by the caretaker” “I think in fact here in rural areas you attend to adults and children, if there are a lot of patients in the morning, so it becomes very difficult to stick to that.” “the booklet takes too long, especially when you have too many patients” ( MT Chipata)

14. Sample responses from Key Informants/Focus Group Discussions Role of stigma in adherence to the HIV guidelines Caretakers who are not biological parents are often not open to discussing HIV Non-disclosure of mother’s own HIV status to spouse made it difficult for the mother to discuss the HIV status of the infant with the health worker Role of supervisory visits “I had stopped using the algorithm but when I was visited... I was forced to start using the IMCI algorithm…“ “It really helps us to follow the guidelines properly; it encourages us to do what you are expected to do instead of short cuts.” “It helped me to follow the steps in the guidelines properly instead of jumping some parts” (MC in Chadza)

15. Discussion Issues highlighted in this survey suggest that inclusion of HIV in the IMCI algorithm and training the health workers may not necessarily translate into effective usage: Pressure of work (Overburdened) Shortage of staff Perception that HIV is not an emergency Lack of privacy in the screening rooms Stigma in the communities Infrequent of use of the guidelines Guidelines not user-friendly

16. Discussion Supervision cited as a key element to ensure adherence to HIV guidelines Supported by Chitembo et al “The impact of health centre based supportive supervision on performance of health workers trained in IMCI” noted that: Performance was better in the intervention site where there was constant supervision Performance may be affected negatively due to high staff attrition leading to increased work load

17. Conclusion Health workers may not necessarily find the HIV guidelines difficult to follow but barriers may exist which prevent them from adhering to the guidelines. Among these are: Poor staffing levels, prevailing stigma among the community and /or health workers infrequent supervision of the health workers, and lack of simplified wall charts. Addressing these barriers is critical in increasing the uptake of paediatric ART

18. Recommendations Improve staffing levels (Improve adherence and more quality time for the patient) Intensify health worker and community programmes to reduce stigma Provide conducive environment for screening at the health centre level Intensify effective supervision Provide simplified IMCI Job Aides e.g. wall charts Incorporate HIV counselling as part of IMCI training Allocate more time to the HIV component during IMCI training

19. References Chitembo et al (May 2005): Impact of health centre based supportive supervision on performance of health workers trained in IMCI, ARCH Project, Lusaka, Zambia MOH (2006): Provincial and district IMCI planning and orientation guidelines, Lusaka, Zambia MOH (2001): IMCI health facility survey report, Lusaka, Zambia MOH(2008):ZDHS preliminary report

20. Acknowledgements District Directors of Health and staff from Kalulushi, Chingola, Mufumbwe, Kapiri-Mposhi, Mkushi, Chipata and Chadiza districts for their cooperation during the survey. Medical students who assisted in data collection HSSP project staff and management

21. Thank You!