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What factors are associated with compliance of integrated management of childhood illness guidelines in Egypt? An analysis using the 2004 egypt service provision assessment survey
Authors: E. Aranda, D. Marron, and A. Roess
Source: Annals of Global Health, 81(1): 187; DOI:
Topic(s): Child health
Children under five
Country: Africa
Published: FEB 2015
Abstract: Background: 6.6 million children under the age of five die annually from preventable diseases. The United Nations Children’s Fund and WHO developed the Integrated Management of Childhood Illness (IMCI) strategy in 1992 to reduce mortality and morbidity largely due to preventable diseases. This study explores whether provider, facility, region, child, and caregiver characteristics are associated with compliance with IMCI clinical guidelines in Egypt to ultimately identify priority program and project area improvements. Methods: The study uses child health service data from the 2004 Egypt Service Provision Assessment Survey (ESPA). The ESPA collects data about health facility service delivery, compliance with standards of care, and client and provider service delivery satisfaction. A nationally representative sample of 659 health facilities were surveyed, of which 479 provided child health services. The child health module consists of facility, provider, and caregiver surveys. The sample consists of 2,071 child observations (1,164 were male). Two multivariate regression models were developed to identify statistically significant predictors of observed care. Findings: Full compliance was low. About 70% of physicians checked for fever, 36.3% weighed the child, and 17.6% checked for anemia (childhood anemia is a major public health concern in Egypt). In only 3% of child visits were caregivers asked about three key danger signs and three or more key symptoms as per IMCI guidelines. Compliance was higher for providers who had received IMCI training and for younger children. After controlling for the patient’s and provider’s demographics and background and facility characteristics, we found that providers with IMCI training had a significantly greater odds of asking two or more danger signs adjusted odds ratio (AOR)¼6.7 (95%CI 3.8, 12.9) if the patient had diarrhea, AOR¼6.2 (95%CI 3.5-10.9) for cough/respiratory, and AOR¼6 (95%CI 3.7, 9.7) for fever. No evidence was found that compliance is associated with child sex, caregiver attributes (except in cases of diarrhea), or region. About half of health care facilities lacked handwashing equipment in the exam room, reliable electricity, and generators. Interpretation: Two ESPAs have been conducted in Egypt. This study recommends a new one to be carried out. Following the 2011 revolution, Egypt experienced a severe economic downturn. Anecdotal evidence points to the deterioration of quality of care in government facilities serving low-income populations. IMCI is a promising strategy to improve quality of care and thereby reduce childhood morbidity and mortality, but compliance is low. The findings illustrate the potential for further analysis of the factors that influence compliance. The small sample size for private facilities, however, limited analysis for comparison with government facilities. Missing data reduced sample size significantly for some regressions and prevented others. Research to understand provider practices and motivations is needed. Funding: None.