Experiences of Primary Health Care Nurses in Implementing Integrated Management of Childhood Illnesses Strategy at Selected Clinics of Limpopo Province

Integrated M anagem ent o f Childhood Illnesses; P rim ary health care nurse; Prim ary health care; Superm arket a p ­ proach. Abstract: Curationis 32 (3): 60-71 Treatment o f the underfive yea rs is a national p riority as an attem pt in curbing deaths and deformities affecting children. Prim ary health care was implemented in the clinics in order to help in the treatm ent o f illnesses affecting the community, including children. As a result o f childhood illnesses; the World Health O rganization (WHO) and United Nation Children's Fund (UNICEF) came up with Integrated Management o f Childhood illnesses (IMCI) strategy to enhance treatm ent o f such illnesses in developing countries. Prim ary health care nurses (PHCNS) in Limpopo province were also trained to implement the strategy. This study is intended to explore and describe the experiences o f PH CNS in im ple­ menting the IM CI strategy a t selected clinics in Vhembe D istrict in the Limpopo Province. A qualitative, explorative, descriptive and contextual design was used. In-depth interviews w ere conducted with PHCNS who are IMCI trained and have imple­ m ented the strategy f o r a p e r io d o f not less than two years. D ata analysis was done through using T esch 's m ethod o f open coding f o r qualitative analysis. Findings revea led that PH CNS had difficulty in rendering IMCI services due to lack o f resources and p o o r working conditions. Recom mendations address the difficul­ ties experienced b y PH CNS when implementing the IMCI strategy.


According to WHO (2004b:2; 2003:1), the aim s o f the IM CI were to identify the childhood illnesses accurately, give appropriate treatment, speed up refer ral o f children to the hospital or any other health service an d give attention to immunization, Vitamin A supplemen tation and exclusive breast feeding. Lis tening, learning an d building confi
dence skills are taught or developed as p a rt o f counselling skills (Kamarag, Lubanga & Heggenhougen, 2004:33).Kam aragi, et. al (2004:31) Arusha in 1995(Red Cross Works, 2003:3;WHO, 2002:1).

Supermarket approach:
The approach that is used to treat the clien tfor all the pro b lem s in one con su ltation a t a health care institution.This means that a client visit the clinic and receive care without givin g specific days f o r sp e cial clinics.

You attend to an ill child, fo llo w ed by one with a wound which needs to be dressed, you have to go to the dress ing room. Then a ch ild comes in with HIV and AIDS-related problem s that w ill need assessment, counselling and testing and so on and so on. You never become settled. You jum p from one ac tivity to another. I work in this fashion from sunrise to sunset). " The superm arket strategy o f rendering health services involves treating p a tients as they consult, without grou p ing them to com e to the clinic on a p a r ticular day o r time. The superm arket stra teg y com bines the various special c lin ic s in to one visit. P a tie n ts are treated as they com e into the consulta tion room f o r w hatever problem they have. There is no longer a flo w o f work. The P H C N m oves fro m one type o f task to another. Participants in dicated that due to the su p e rm a rk e t m eth o d , o n e ty p e o f health education which is to be given to alm ost all the patien ts is to be re p e a te d many times to individual moth ers as they consult. P articipan ts ex p re sse d the giving o f health education in the superm arket m ethod as fo llo w s: "When health education is given you also have to repeat yo u rself many times because patients who need the same type o f health education w ill be com ing one by one a t different times. A t the en d o f the day yo u s till have to repeat. This becomes boring and tire some ". This can be tim e-wasting and tiresom e and the education is not given logically. M others end up not gettin g the sam e inform ation. This is su p p o rted b y a study done by Nem athaga (2005:64), that when using the superm arket ap proach health education is not given the attention it deserves. She agues that health education is either not given, o r i f given, it is done haphazardly be cause the P H C N does not have enough time f o r this. P H C N indicated that shortage o f human resources is further com plicated by the many activities that have been introduced without increas ing the staffing. IMCI, like any other strategy, increased the workload. A ll these activities in crea sed the w orkload o f the already overworked PHCN. " With us the s ta ff is s till the same from the time when PH C was implemented, the fr e e health services, supermarket strategy and now IMCI. There is no change o f staff. We a re now o ver worked. This has affected other activi ties such as implementation o f IMCI, home visits an d participation in the community project, o f which we are expected to have one each y e a r " "I cannot make it. I see more than 40 babies p e r day. This excludes the other patients. " This is supported by M cCoy, Besser, V issera n d D o h e rty's (2002:36) study, which confirms that when prevention o f m o th e r to c h ild tr a n s m is s io n (PMTCT) was introduced the workload was a d ded but this was not com pen sa te d f o r b y a d d itio n a l staff. WHO (2003-2007:14) supports this as it indi cates that the introduction o f PM TCT an d an tiretroviral therapy (ARVT) in Botswana, resulted in increased work lo a d f o r the a lre a d y o v e rstre tc h e d workforce resulting in overw orking o f staff. This im plied that the PH C N ren dering IM CI services a t Shayandima catchm ent area who are also im ple menting the very PMTCT, AR VT and IM CI are not exceptional.
According to the stu dy by Wirzba and Juncker (1995:33)

The assessm ent o f a child is obviously not accurate as they are going to use subjective data. This was supported by the participan t who said:
"The broken therm om eters are not quickly replaced.This makes it dijfi-

cult f o r me to use accurate informa tionfor making the right diagnosis and treatment in IMCI. A t times I ju s t refer the ch ild to the hospital because the c h ild ' s body is hot. What can I do? (Facing a t me like I would come up with an answer MM....!) There is noth ing that I can do (With low voice). ''
According to WHO (2002:23)

The researcher ob served that the clin ics h ad no com puters. In su pport o f this the P H C N sa id that: "There are no computers in the clin ics. Computers may be very useful fo r recordkeeping, information and p r o duction o f different form s that are use f u l a t the clinic including the very as sessmentforms that are used every day f o r every child. '' A ccording to Critchton an d Botman (2002:22-27) the University o f the Free State d evelo p ed a W orld Wide Web (WebCT) course to o l which p ro vid es the softw are tools n ecessary to create, d eliver an d manage an IM C I course over the WebCT. So the P H C N would be able to access this information i f there were com puters with internet f a cilities a t the clinics. This w ould also help to update the P H C N with recent developm ents and knowledge in IMCI.
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Participants in some clinics indicated that there was no suitable space fo r preparation o f a dehydration comer. In support o f this, participants said: "There is no open space as the rooms are very smalL This fa ils us to imple ment the rehydration plan f o r a dehy d rated baby according to the IMCI standards. " Another participan t said:
"There are two consultation rooms with one sm a ll w aiting room, one dressing room and one labour ward.

In the mornings when clients are s till many, som e o f the p a tie n ts w ait on benches outside on the veranda. ïou can see fo r yo u rself where we have p rep a red the rehydration corner, it is not even visible to you. " A ccording to the WHO an d UNICEF (2002a:20), a standard rehydration cor ner is su pposed to be in a c o m e r which the staffm em bers frequ en tly pass, near to a w ater sou rce an d w ell ventilated. The corn er sh ould have inform ative p o ste rs displayed. A ccording to WHO an d UNICEF (2002a:67), the instruc tions in the rehydration corner should be in words and pictures. This w ill help with the education o f the m other while she sits th erefor treatment o f the baby.
• WHO (2002:22-26), IMCI strategy implemen tation uses three strategies when tar g etin g a case, that is, management, community involvement and improving the health system .So IM CI needs a cooperative community.

Recommendations
The fo llo w in g recom m endations were m ade based on research findings, to ensure effective implementation o f the IM CI strategy b y the PHCNS.

According to Karamagi, et. a l (2004:39) time required fo r case management var iedfrom 8-20 minutes. I f these findings are applied a t Shavandima catchment area where they work 8 hours p e r day, this means that a PH CN will be able to treat about 7 children p e r da y when using IM CI strategy. The presen t sta ff establishm ent is f a r less than this ex pectation.
There is therefore a need to increase staff.

The r e s e a r c h w a s c o n d u c te d in Vhembe D istrict under Shayandim a catchment area an d this m ay not nec essarily represent the experiences o f all PH CN S renderin g IM C I services in
Lim popo Province.The findings can not be generalized.

References
about PH C N S' experiences regarding implemention o f IMCI, as this was a new strategy.The researcher wanted to fin d out how the PH CN S w ere expe riencing the implementation o f the IMCI strategy, in order to identify areas that needed im provem ent b a sed on the in form ation gath ered fro m nurses who were involved with it on daily basis.In o rd e r to u n d ersta n d the co n tex t in which the PH CNS are functioning, the resea rch er a sk ed the fo llo w in g two questions which g u ided the study: is conducted to explore the dimensions o f a phenomenon, the man ner in which it is m anifested and the o th er f a c to r s which are related.As IM C I strategy is new, the researcher decid ed to use the explorative design to pu rsu e the experiences o f a child with a tem perature o f 38 degrees C el sius should be given Paracetam ol every 6 hours.Chaudhary, M oh anty an d Sharma (2005:739) fou n d that health workers working without thermometers or minute sound tim ers com prom ises the assessm ent o f children an d m ay lea d to wrong assessment, diagnosis and treatment.
Oh, what a re lie f " This su pports a stu d y b y Lehmann and Saunders (2002:133) that som e South African nurses g o a b ro a d b e ca u se o f p o o r w o rk in g co n d itio n s.
night and re gardless o f working during the night, they w ere expected to work a fu ll day the fo llo w in g day.In som e instances the P H C N w ould be working with the en rolled nurse, an d w as expected to consult all the patients.They associ ated this with lack o f sleep and rest, with tiredness, headaches, forgetfu l ness an d loss o f concentration."I report on duty on Wednesday and g o home the fo llo w in g Wednesday.Meaning that I take 7 nights call.Iam expected to work a f u ll day irrespec tive o f whether I have worked during the night or not.Whether I am tire d or not, though we are com pensated on this but it is not healthy a t a ll ''This study revea led that the PH CN S' working conditions left them without enough sleep.PH CN S indicated that they had very little tim e to sleep when they w ere on call, since they cou ld be called at any time to attend to a patient who needed em ergency attention.In alm ost all the clinics participants in d icated that they h ad to take calls and in sp ite o f w orking during the night they w ere ex p ected to w ork norm al hours the fo llo w in g day.
Y , A 2002.D oing and writ ing qualitative research.London: Sage.IG U M BO R , EU; BR A D SH O W , D & LAUBSCHER, R2003: Morbidity Pro f i l e fr o m r e g is te r e d d ea th s f o r the Limpopo ccupational stress in nursing.International Journal o f Nursing Studigs.40(5)555-565.M E R R IC K , J 2003: P revalen ce o f childhood illnesses and care in rural UgandaChild and adolescent health and development, Analytic review o f IMCI strategy> .WORLD HEALTH ORGANISATION.

The researcher used her ju dgm en t to determ ine the size o f the sam ple since there w ere not m any participan ts, and not much had been researched about this topic. This a llow ed participan ts to articulate their experiences since IMCI was still a new strategy that was being implemented. A ccording to B abbie and Mouton (2002:288), adequate time and current involvem ent are criteria f o r se lection o f p a rticip a n ts who have the best answers to the research question. In this research the sam ple was fo rm ed by PH CN S who: • had undergone a two weeks ' IM CI course; • were rendering IMCI services at Shayandima catchment area, Thulamela M unicipality clinics ofV h em be d istrict in Lim popo Province; • h ad im plem ented the IM CI stra teg y f o r not less than one year; and • had given inform ed voluntary consent to p a rticip a te in the study. According to D e Vos, Strydom, Fouche an d D elp o rt (2002:304) an d H oliday (2002:79), the aim o f data collection is to p ro vid e a contextual experience, re vealin g an experience as a p rocess. A ccording to Newman (2000:33), it is through skill, p ra ctice an d creativity that one m atches. a research question to an appropriate data collection tech nique.
A c c o r d in g to B u rn s a n d G