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Care for infants and young children: implementation review and planning guide: care for infants and children services

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Care for infants and young children Implementation review and planning guide: care for infants and children services PRIMARY HEALTH CARE QUALITY IMPROVEMENT GUIDE MODULE 3

Care for infants and young children Implementation review and planning guide: care for infants and children services Primary Health Care Quality Improvement Guide: MODULE 3 Care for infants and young children: implementation review and planning guide: care for infants and children services (Primary Health Care Quality Improvement Guide: Module 3) © World Health Organization 2024 ISBN 978 92 9062 042 6 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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Shimizu CONTENTS Acknowledgements................................................................................................................................................................................................................................................................................................................................................................................................... v Abbreviations ................................................................................................................................................................................................................................................................................................................................................................................................................................. vi Foreword ...................................................................................................................................................................................................................................................................................................................................................................................................................................................... vii About the Primary health care quality improvement guides ........................................................................................................................................................................................................................ viii INTRODUCTION ................................................................................................................................................................................................................................................................................................................................................................................................................. 1 1. Scope and purpose of this guide ..................................................................................................................................................................................................................................................................... 1 2. Approach used to improve the quality of primary health care for child health ............................................. 3 SECTION 1. Facility assessment ..................................................................................................................................................................................................................................................................................................................................... 7 1. Interviews with caregivers of sick and well children ....................................................................................................................................................................... 8 2. Chart review and re-examination of sick children after interview ........................................................................................................ 31 3. Observations of environmental hygiene and promotional materials in outpatient clinics .................................................................................................................................................................................................................................................................................................................................. 37 4. Review of availability of essential medicines and supplies for child health services at outpatient clinics ....................................................................................................................................................................................................................................................................................... 41 5. Review of policies, guidelines and standards for child health services ......................................................................................... 46 6. Register review — sick-child outpatient clinics ............................................................................................................................................................................................... 50 7. Review child health training status of outpatient staff.............................................................................................................................................................. 52 SECTION 2. Develop a facility action plan .................................................................................................................................................................................................................................................................................... 54 SECTION 3. Synthesize findings from a review of several facilities .................................................................................................................................................................. 56 Checklists 1–7: Summary form for all health facilities ............................................................................................................................................................... 57 SECTION 4. Review monitoring and evaluation data for child health ........................................................................................................................................................ 59 SECTION 5. Use findings to develop an annual implementation plan for improving child health .............................. 66 1. Identify priority problems ...................................................................................................................................................................................................................................................................................................... 66 2. Develop an annual child health action plan .................................................................................................................................................................................................................. 68 TABLES AND CHECKLISTS TABLES Table 1. Core survive-and-thrive interventions for infants and young children ..................................................................................................................... 2 Table 2. Key steps of the child health review at primary-care clinics (hospitals, health centres and health posts) ......................................................................................................................................................................................................................................... 4 Table 3. Priority actions to improve child health services at outpatient clinics .............................................................................................................. 55 Table 4. Benchmarks of scale-up readiness, 2023–2027 .................................................................................................................................................................................................................. 60 Table 5. Health facility child health standards, 2023–2027 ........................................................................................................................................................................................................ 61 Table 6. Coverage indicators for child health interventions, 2023–2027 .......................................................................................................................................... 63 Table 7. Impact indicators for child health, 2023–2027 ......................................................................................................................................................................................................................... 65 Table 8. Synthesis of review findings: national sample of health facilities ..................................................................................................................................... 67 Table 9. Annual action plan for improving child health at outpatient facilities ................................................................................................................ 69 CHECKLISTS Checklist 1.1 Infant and young child feeding, and advice on danger signs: interview with the caregiver ............................................................................................................................................................................................................................................................................. 9 Checklist 1.2 Vaccinations and vitamin A: interview with the caregiver ................................................................................................................................... 13 Checklist 1.3 Screening, management and prevention of diarrhoea: interview with the caregiver ...... 16 Checklist 1.4 Screening and management of cough and difficulty breathing: interview with the caregiver ............................................................................................................................................................................................................................................................................. 20 Checklist 1.5 Screening and management of fever: interview with the caregiver ..................................................................................... 22 Checklist 1.6 Screening and management of HIV: interview with the caregiver ............................................................................................ 23 Checklist 1.7 Screening and management of injuries, abuse and neglect: interview with the caregiver ............................................................................................................................................................................................................................................................................. 24 Checklist 1.8 Early child development: interview with the caregiver .................................................................................................................................................. 27 Checklist 2.1 Basic health screening: sick and well children ....................................................................................................................................................................................... 32 Checklist 2.2 Chart review and re-examination of the sick child ................................................................................................................................................................... 33 Checklist 3 Environmental hygiene and promotional materials ............................................................................................................................................................. 38 Checklist 4 Review of availability, storage conditions and validity of essential medicines and supplies for child health services at outpatient clinics ........................................................................................................................... 42 Checklist 5 Review of policies, guidelines and standards for child health services at outpatient clinics ................................................................................................................................................................................................................................................................................................................... 47 Checklist 6 Validation of reported child health data using facility records .............................................................................................................. 51 Checklist 7 Staff training summary: well- and sick-child outpatient clinics ....................................................................................................... 53 Checklists 1–7 Summary form for all health facilities ................................................................................................................................................................................................................................ 57 Primary health care quality improvement guide — Module 3: Care for infants and young children iv vACKNOWLEDGEMENTS The Maternal Child Health and Quality Safety (MCQ) unit of the WHO (World Health Organization) Regional Office for the Western Pacific would like to thank all health facility and programme staff who contributed to the review and field-testing of Primary health care quality improvement guide — Module 3: Care for infants and young children. Dr John Murray, Dr Priya Mannava, Dr Li Zhao and Dr Howard Sobel were the primary authors, and managed testing and development of the guidelines. Special thanks are extended to country partners who coordinated and managed early implementation, and made valuable contributions to the final Module, as follows: Cambodia — From the Ministry of Health: Professor Tung Rathavy, Director, National Maternal and Child Health Centre; Dr Krang Sidonn, Deputy-Director, Communicable Disease Control Department; Dr Lim Hun, Technical Officer, Communicable Disease Control Department; and Mr Kuoch Sokdararith, Technical Officer, Communicable Disease Control Department. From the WHO Cambodia country office: Dr Sano Phal, National Professional Officer. China — From the Capital Institute of Paediatrics: Dr Dai Yaohua, Professor of Pediatrics, Head, WHO Collaborating Centre for Child Health; Dr Zhang Yanfen, Professor of Pediatrics, Director, Department of Child Development; Dr Zhang Shuaiming, Associate Professor of Pediatrics, Department of Child Nutrition; Dr Li Tao, Assistant Professor of Pediatrics, Coordinator, WHO Collaborating Centre for Child Health; and Dr Jia Ni, Assistant Professor of Pediatrics, Department of Child Development. Lao People’s Democratic Republic — From the Ministry of Health: Dr Phonepaseuth Ounaphom, Director General of Department of Hygiene and Health Promotion; Dr Souvankham Phommaseng, Deputy Chief of Health Promotion Division, Department of Hygiene and Health Promotion; Dr Khamseng Philavong, Deputy Director of Nutrition Center; and Dr Phouthong Rattanavong, Head of Child Section, Mother and Child Health Center. From the WHO Lao country office: Dr Shogo Kubota, Reproductive, Maternal, Nutrition, Child and Adolescent Health (RMNCAH) Team Leader; Dr Outhevanh Kounnavongsa, RMNCAH Technical Officer; Ms Sylivanh Phomkong, RMNCAH Technical Officer; and Dr Daisuke Asai, Short-term Consultant. Mongolia — From the Department of Medical Services, Ministry of Health: Dr Ulziikhutag Enkhmaa, Officer for Child Health. From the WHO Mongolia country office: Dr Delgermaa Vanya, Technical Officer. Philippines — From the Department of Health: Dr Cherylle C. Gavino, Officer-in-Charge, Director III, Disease Prevention and Control Bureau, Lead for Technical Integration. From the WHO Philippines country office: Dr Jacqueline Kitong, RMNCAH Technical Officer. Viet Nam — From the Ministry of Health: Dr Dinh Anh Tuan, Vice Director; Dr Nguyen Mai Huong, Officer, Maternal and Child Health Department. From the WHO Viet Nam country office: Dr Pham Thi Quynh Nga, Technical Officer. Primary health care quality improvement guide — Module 3: Care for infants and young children vi ABBREVIATIONS CRVS civil registration and vital statistics DHS Demographic and Health Survey HMIS health management information system IMCI Integrated Management of Childhood Illness IU international unit MICS Multiple Indicator Cluster Survey ORS oral rehydratation salt RHF recommended home fluid SDG Sustainable Development Goal WHO World Health Organization vii FOREWORD The World Health Organization (WHO), Member States and stakeholders in the WHO Western Pacific Region believe that children represent the future. Ensuring their healthy growth and development should be paramount in all societies. In the Region, the estimated mortality rate of children under the age of 5 was reduced by 65% between 1990 and 2011. This represented a decline in the total number of deaths of nearly 80%. Yet despite this progress, some 1052 children under 5 still die each day, mostly from problems in the newborn period (prematurity, sepsis and asphyxia) and pneumonia and diarrhoea in older children. In every country, poor, rural and less-educated groups remain at high risk. In addition, ensuring that all children maximize their potential means that more attention should be given to issues that have not been addressed well in the past, including improving early childhood development; reducing maltreatment, abuse and injuries; and tackling the emerging problem of childhood obesity. Frontline health workers remain the most effective resource for managing sick children, screening them for preventable problems, and providing critical counselling and family support. However, many frontline health workers do not have the skills or support to provide some of these essential services. This guide outlines an approach for assessing and improving the quality of primary health care for both sick and well children. It builds on the need for bottom-up planning and action by engaging local staff in identifying and solving problems themselves. By collecting and monitoring facility data, progress can be tracked and continuously improved. Together, we must push to meet the health-related targets of the Sustainable Development Goals (SDGs): reduce preventable newborn and child mortality (SDG target 3.2); significantly reduce poverty (SDG 1) and hunger (SDG 2); improve the quality of education (SDG 4); ensure gender equality (SDG 5); and provide access to clean water and sanitation for all (SDG 6). WHO, Member States and stakeholders must work together to reach these ambitious goals to ensure high-quality primary health-care services for all women, families and children in the Region. Primary health care quality improvement guide — Module 3: Care for infants and young children viii ABOUT THE PRIMARY HEALTH CARE QUALITY IMPROVEMENT GUIDES 1. PREVENTING UNPLANNED PREGNANCIES Implementation review and planning guide: outpatient family planning services 2. ANTENATAL CARE Implementation review and planning guide: antenatal care services 3. CARE FOR INFANTS AND YOUNG CHILDREN Implementation review and planning guide: care for infants and children services Modules can be used individually or at the same time, depending on programme needs and priorities. There are three Primary health care quality improvement guides 1INTRODUCTION 1. Scope and purpose of this guide This guide is used to identify strengths and gaps in the quality and availability of core “survive-and- thrive” interventions for infants and young children at primary-care facilities (TABLE 1).1,2 The focus is on all children from birth to 3 years of age who are at highest risk of morbidity and mortality. Survive interventions address illnesses accounting for most deaths of children and include vaccination, Integrated Management of Childhood Illness (IMCI), and infant and young child nutrition. Thrive interventions ensure early childhood development and prevention of disabilities, injuries, violence, abuse and neglect. All programmes must ensure survive-and-thrive interventions are delivered effectively. As coverage of survive interventions increases and child mortality declines, thrive interventions are usually added. 1. Primary-care facilities are health centres, health posts or outpatient departments of hospitals. 2. While pre-referral care is covered, advanced management of these cases is beyond the scope of this guide. Similarly, programmes not administered through health facilities, such as iodized salt distribution, are excluded from this guide. 2 Primary health care quality improvement guide — Module 3: Care for infants and young children TABLE 1 Core survive-and-thrive interventions for infants and young children Clinical area INTERVENTIONS Survive Thrive 1. Infant and young child feeding » Exclusive breastfeeding for 6 months » Complementary feeding starting at 6 months » Continued breastfeeding for at least 2 years 2. Nutrition » Growth monitoring » Management of severe and moderate acute malnutrition without complications » Management of micronutrient deficiencies » Vitamin A supplementation in vitamin A-deficient populations » Deworming and iron supplementation for preventing and managing childhood anaemia » Prevention and management of underweight and stunting » Prevention and management of overweight and obesity 3. Vaccination » Routine immunizations, including Haemophilus influenzae type B » Meningococcal, pneumococcal and rotavirus vaccination 4. Prevention and management of common childhood illnesses » Use of insecticide-treated bed nets » Case management of malaria and fever » Case management of uncomplicated pneumonia and wheezing » Case management of diarrhoea and dysentery » Recognition, pre-referral treatment and referral of severe or complicated cases » Screening of family history 5. HIV and tuberculosis » Screening of children with or exposure to HIV or tuberculosis or who have severe acute malnutrition » Appropriate treatment and referral » Counselling, maintenance care, nutritional and psychosocial support 6. Injuries » Management and referral of acute common injuries (falls, fractures, drowning, head injury) » Anticipatory guidance to avoid injuries 7. Early childhood development » Screening, management and referral for developmental delay, disability, maltreatment and signs of abuse » Promotion of home activities to foster learning, school readiness and use of early childhood education 32. Approach used to improve the quality of primary health care for child health Improving the quality of primary health care requires continuous monitoring by facility staff and periodic external evaluations of care to support district, provincial and national planning. This guide provides tools to support both continuous monitoring and periodic evaluations. The core of the approach are checklists to assess the quality of clinical care, policies, supplies and environments. From these checklists, areas needing improvement and actions to address these areas are identified for the individual primary health facility (TABLE 2, Sections 1 and 2). For periodic evaluations, external teams use the same checklists to assess services from multiple health facilities across a national or subnational area and develop plans using the data (TABLE 2, Sections 3–5). CHILD HEALTH REVIEW AT PRIMARY-CARE CLINICS Assessment and planning to improve child health services at hospitals and health centres A. CONTINUOUS MONITORING PROCESS A team of facility staff pair with a trained external facilitator to begin the process of child health review and planning. The team is trained in the methodology. They then conduct an assessment with facilitator support and develop a three-month quality improvement plan. Subsequently, internal self-assessments are repeated by the facility staff to track progress. PARTICIPANTS From two to four facility staff are recommended and should include the facility manager and staff providing clinical care. In the outpatient departments of larger hospitals quality-assurance staff may also be available. TIMING One day for facility review and development of an action plan. 4 Primary health care quality improvement guide — Module 3: Care for infants and young children TABLE 2 Key steps of the child health planning review at primary-care clinics (hospitals, health centres and health posts) TOOL METHOD Continuous facility monitoring Periodic evaluations SECTION 1. Conduct facility assessment Checklists 1.1–1.8 » Chart reviews and interviews with caregivers of children 0–3 years (survive-and-thrive interventions) ü ü Checklists 2.1–2.2 » Basic health screening » Re-examination of sick children ü ü Checklist 3 » Observations of environmental hygiene and promotional materials ü ü Checklist 4 » Review of essential medicines and supplies ü ü Checklist 5 » Review of policies: support of child health practices ü ü Checklist 6 » Review of sick- and well-child registers ü ü Checklist 7 » Review of staff coaching for child health ü ü SECTION 2. Develop a facility action plan Table 3 » Use of data to determine priority actions for a three-month plan ü ü SECTION 3. Synthesize findings from a review of multiple facilities Checklists 1–7 Synthesis tables » Synthesis of facility review findings across a sample of facilities ü SECTION 4. Review monitoring and evaluation data for child health Tables 4–7 » Completion of monitoring and evaluation tables ü SECTION 5. Use findings to develop an annual implementation plan for improving child health Tables 8–9 Annual action plan » Completion of action framework – and links with previous plan ü * The checklists and tables listed in the left-hand column refer to the checklists and tables that appear in subsequent pages in this document. 5PREPARATIONS — In advance of facility visits: 1. Ensure the external facilitator is trained in Integrated Management of Childhood Illness (IMCI), has experience with assessment, classification and treatment of children, and has copies of the country’s IMCI chart booklet for re-examination of sick children. 2. Obtain clearance for facilitators to visit selected health facilities from hospital directors, local health officers and subnational authorities. This is usually accompanied by a letter of introduction from the health ministry to present at the courtesy call with the facility chief or designate. 3. Secure a budget for per diem to support field visits, transportation, photocopying and other costs. 4. Identify one or two health facility staff to organize the review, learn the approach and coordinate implementation of the facility plan. B. PERIODIC EVALUATIONS At district, subnational or national levels PROCESS A team of facility evaluators are trained at a central venue. They visit a sample of primary-care facilities and complete the checklists. They return to a central venue to summarize and review data. PARTICIPANTS At least 12 evaluators are needed and may include members of district, provincial or national child health departments or facility child health teams. Other health ministry staff and development partners may participate in data analysis and planning. At least one member of each team visiting facilities must be trained in IMCI and have experience with assessment, classification and treatment of children. TIMING The process requires from six to eight days: one day for preparation with the review team; from three to five days for fieldwork; and two days for data analysis, interpretation and use of data for annual planning. 6 Primary health care quality improvement guide — Module 3: Care for infants and young children SITE SELECTION Depending on the level and number of facilities to be assessed, two options are possible: » OPTION 1 — Include all health facilities that have begun facility monitoring within the past year. Participants can be health facility staff and facilitators, as well as external staff. » OPTION 2 — Randomly select at least 18 facilities for a national review or for each subnational area of interest (district, province or region). Include at least three national or regional hospitals, three provincial hospitals, six district hospitals (two in each selected province) and six first-level facilities (one in each selected district). If the subnational area of interest has fewer hospitals, then replace hospitals with primary-care facilities. Twelve evaluators are paired in six groups, and each group visits three facilities in three to five days. PREPARATIONS 1. Obtain clearance to visit selected health facilities for fieldwork from national and subnational authorities. Ideally, selected facilities will not be notified in advance of field visits. 2. Ensure availability of: a. Meeting venue for the first and last two days. b. Supplies: pencils, flip-chart paper and markers. c. Documents: national child health action plan, last annual implementation plan, fieldwork data collection sheets and timetable. d. Budget for per diem for the review team members, transportation for field visits, venue, materials, supplies, photocopying and other costs. e. Letter of introduction from the ministry of health to present at the courtesy call with the hospital chief or designate. 3. Complete the child health monitoring and evaluation tables, except sections that require data from the facility evaluation. 7SECTION 1 Facility assessment Facility name: ............................................................................................................................................................................................................................................................................................................................................................................................................................................. Province: .................................................................................................................................................................................. District: ........................................................................................................................................................................................................................ Date(s) of visit(s) (DD/MM/YY) ......................................................................................................................................................................................................................................................................................................................................................... Review conducted by: ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Informants / staff interviewed to complete data collection tools: ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 8 Primary health care quality improvement guide — Module 3: Care for infants and young children 1. Interviews with caregivers of sick and well children Caregivers are interviewed to understand the effectiveness of the health system to deliver essential services to infants and young children. INSTRUCTIONS 1. Arrive at the facility before clinic sessions begin. Identify sick- and well-child clinics. Find a room away from patients and staff to conduct interviews. If this is not possible, locate a quiet corridor or corner where the conversations can be private. 2. Select five children aged 0–3 years from sick- and well-child registers in the order they were registered prior to being seen by the health worker on the day of the review. If five or fewer sick or well children are registered, select all children and use the sick- and/or well-child registers to identify additional cases as they arrive. If insufficient numbers (five each) are available at the clinic on the day of the visit, review registers for the previous clinic day(s) and randomly select the required number of children. If possible, use mobile phone numbers to conduct phone interviews with caregivers or ask women to come to the facility for an interview on the day of the visit. Alternatively, use addresses to visit households and conduct interviews directly. 3. Ask the caregiver of each selected child if they will wait after the clinic consultation for a short interview. Ask staff to ensure that selected caregivers and children wait for an interview. After each consultation, ask staff for the child’s case records. 4. Obtain verbal informed consent by stating: “This interview aims to understand how we can help improve care for all children in the country. Everything you say here will be kept confidential, meaning no one will know what you said. Anytime you want to stop, you may. Your child’s care will remain the same. The interview will take about 15 minutes. Do you agree to do this interview?” Record informed consent. 5. Unless otherwise specified, ask all questions to the caregiver. For questions on nutrition, use the child’s card or record to determine the child’s nutrition z-score before asking questions to the caregiver. For questions on vaccinations, refer to the child’s vaccination record first; if it is not available, ask the caregiver. 6. Record findings in Checklists 1.1–1.8 indicating Y (“Yes“), N (“No“), DK (“Do not know”) or as otherwise instructed in the questions. Since “No data” is also a very important piece of information, indicate NR (“Not recorded“) in appropriate questions. CH EC KL IS T 1. 1 ( 1 /3 ) 9Infant and young child feeding, and advice on danger signs: interview with the caregiver QUESTION Ask the caregiver. Answer the questions with available data or with: Y (yes), N (no), or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Verbal informed consent obtained? 2. Name of the child 3. Sex of the child (M or F) N = F 4. Age of the child (in months) 5. Is the child breastfeeding? If “No”, skip to Question 7 — If “Yes“: a. Do you have any difficulties breastfeeding? 6. Are any fluids other than breastmilk being given? Write “Yes” for all that apply. a. Water? b. Sugar water? c. Powdered milk formula? d. Sugar-sweetened beverages (including juices, soft drinks, flavoured milks)? e. Other, please specify: ....................................................................................................................... Other fluids: 7. Is the child < 6 months? If “No”, skip to Question 11 8. Summary: Is the child < 6 months exclusively breastfed? Answer “Yes” only if Questions 6.a–6.e = “No” 9. Did the health worker: a. Ask if the child is breastfeeding? b. Check breastfeeding position and attachment? c. Ask how many times a day the child breastfeeds? d. Ask about any difficulties or concerns with breastfeeding? e. Ask about other fluids or foods being given? CHECKLIST 1.1 (1/3) CHECKLIST 1.1 CHECKLIST 1.1 (2/3) QUESTION Ask the caregiver. Answer the questions with available data or with: Y (yes), N (no), or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 10. Summary: Did the child < 6 months receive breastfeeding screening? Answer “Yes“ if at least three of the Questions from 9.a to 9.e = “Yes“ 11. Did the health worker give you advice or counselling on breastfeeding? 12. Is the child ≥ 6 months? If “No”, skip to Question 16 — If “Yes“: a. What types of food do you give your child on a typical day? 1 b. How often does your child eat (semi-)/solid food on a typical day? c. How often does your child breastfeed on the typical day? d. Do you have any difficulties or concerns with feeding foods? 13. Summary: Does the child eat four or more types of food each day? Answer “Yes“ if Question 12.a lists four or more types of food 1 14. Summary: Does the child eat an appropriate number of times per day? Answer “Yes“ if Question 12.b lists: (semi-)/solid foods 2x/day for infants aged 6–8 months or 3x/day for children 9–23 months (breastfeeding), and 4x/day (non-breastfeeding). 2 15. Did the health worker ask: a. What types of food do you give your child on a typical day? 1 b. How often does your child eat food on a typical day? c. Do you have any difficulties or concerns with feeding foods? 16. Summary: Did the child receive complementary feeding screening? Answer “Yes“ only if Questions 15.a–15.c = “Yes“ 17. Did the health worker advise or counsel you on how to feed your child properly? 18. Do you give any foods fortified with micronutrients? (local name: ....................................................................................) CHECKLIST 1.1 (3/3) 10 CHECKLIST 1.1 11 CHECKLIST 1.1 (3/3) QUESTION Ask the caregiver. Answer the questions with available data or with: Y (yes), N (no), or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 19. Did the health worker advise or counsel you on the use of micro- nutrient powders? (local name: ........................................................................) 20. Did the health worker advise/counsel you on danger signs that mean your child should be brought immediately to the clinic or hospital? 21. Can you name danger signs that mean that your child should be brought immediately to the clinic or hospital? Write “Yes“ for signs identified without prompting. a. Not feeding well b. Unable to drink or breastfeed c. Vomits everything d. Convulsions e. Fast breathing f. Severe chest in-drawing (chest wall pulled in between the ribs) g. Low temperature (< 35.5 °C) or fever (> 38 °C) for children < 2 months or ≥ 37.5 °C for children > 2 months h. Movement only when stimulated or no movement at all: lethargic or unconscious i. Any jaundice if age is less than 24 hours or yellow palms and soles at any age 22. Summary: Does the caregiver know at least three danger signs for seeking immediate care? 3 n (0–2 m) = n (2 m–3 y) = * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row; m, month; y, year. 1. Any amount of food from at least four out of the seven following food groups: 1) grains, roots and tubers; 2) legumes and nuts; 3) dairy products (milk, yogurt, cheese); 4) flesh foods (meat, fish, poultry and liver/organ meats); 5) eggs; 6) vitamin-A-rich fruits and vegetables; and 7) other fruits and vegetables. 2. Breastfeeding children: solid, semi-solid or soft foods, two times for infants age 6–8 months, and three times for children 9–23 months. Non-breastfeeding children: solid, semi-solid or soft foods, or milk feeds, four times for children age 6–23 months. 3. Danger signs for children 0–3 years (see the summary table on next page). CHECKLIST 1.1 12 Danger signs for children 0–3 years Age group Danger sign 0–2 months » Not feeding well » Convulsions » Fast breathing (60 breaths per minute or more) » Severe chest in-drawing » Low temperature (< 35.5 °C) or fever (> 38 °C) » Movement only when stimulated or no movement at all » Any jaundice if age less than 24 hours or yellow palms and soles at any age 2 months – 3 years » Unable to drink or breastfeed » Vomits everything » Convulsions » Lethargic or unconscious Sources: Integrated Management of Childhood Illness. IMCI chart booklet. Geneva: World Health Organization; 2014 (https://cdn.who.int/media/docs/default-source/mca-documents/child/imci- integrated-management-of-childhood-illness/imci-in-service-training/imci-chart-booklet.pdf?sfvrsn=f63af425_1). Integrated Management of Childhood Illness: management of the sick young infant aged up to 2 months. IMCI chart booklet. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/326448). CHECKLIST 1.2 (1/2) 13 CHECKLIST 1.2 (1/2) Vaccinations and vitamin A: interview with the caregiver QUESTION Use the child’s vaccination record. If the vaccination record is not available, ask the caregiver. Answer the questions with: Y (yes), N (no), DK (do not know), NR (not recorded) or NE (not eligible) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Age of the child (in months) 2. Vaccination card or record available? 3. Has the child received the following vaccinations? a. BCG vaccine b. HBV1 1 HBV1 birth dose given within 24 hours c. DPT1 1 d. Hib1 1 e. HBV2 1 f. bOPV or IPV1 g. PCV1 h. DPT2 1 i. Hib2 1 j. HBV3 1 k. bOPV or IPV2 l. PCV2 m. DPT3 1 n. Hib3 1 p. bOPV or IPV3 q. PCV3 CHECKLIST 1.2 CHECKLIST 1.2 (2/2) QUESTION Use the child’s vaccination record. If the vaccination record is not available, ask the caregiver. Answer the questions with: Y (yes), N (no), DK (do not know), NR (not recorded) or NE (not eligible) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 r. Measles 1, MR1 or MMR1 2 s. Measles 2 3, MMR1 2 or MMR2 4. Summary: has the child received all needed vaccines (up to date)? 4 5. Is the child < 12 months? If “No”, skip to Question 7 6. Summary: did the child < 12 months receive all needed vaccines (up-to-date)? 4 7. Is the child > 6 months? If “No“, skip to Checklist 1.3 8. Has the child ever received vitamin A? a. Has the child received vitamin A in the past 6 months? 9. Is the child > 12 months? If “No”, skip to Checklist 1.3 10. Has the child ever received deworming medication? 5 (local name: ...............................................................................................................) a. Has the child received a deworming medication in the past 6 months? 5 (local name: ...................................................................... ) * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row, excluding those who are not eligible. BCG, bacille Calmette-Guérin (vaccine); bOPV, bivalent oral poliovirus vaccine; DPT, diphtheria–pertussis–tetanus (vaccine); HBV, hepatitis B vaccine; Hib, Haemophilus influenza type b (vaccine); IPV, inactivated poliovirus vaccine; MMR, measles–mumps–rubella (vaccine); MR, measles–rubella (vaccine); PCV, pneumococcal vaccine 1. Indicate if pentavalent was given. 2. According to national schedule. 3. At least 1 month after first dose of measles-containing vaccine. 4. Vaccines required by age (see vaccination table on next page). 5. To be adapted according to national policy. Preventive chemotherapy (deworming), using annual or biannual single-dose albendazole (400 mg) or mebendazole (500 mg), is recommended as a public health intervention for all young children aged 12–23 months, preschool children aged 1–4 years and school-age children aged 5–12 years (in some settings, up to 14 years) living in areas where the baseline prevalence of any soil-transmitted infection is 20%. See: Guideline: preventive chemotherapy to control soil-transmitted helminth infections in at-risk population groups. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/258983). 14 CHECKLIST 1.2 15 Routine vaccine for children 0–3, by age VACCINES that should have been received to be up to date Age of the child (in weeks and months) 0–5 weeks 6–9 weeks 10–13 weeks 14 weeks– 8 months 9–12 months 13–17 months 18–36 months 1. BCG ü ü ü ü ü ü ü 2. HBV1 ü ü ü ü ü ü ü 3. DPT1 ü ü ü ü ü ü 4. HIB1 ü ü ü ü ü ü 5. HBV2 ü ü ü ü ü ü 6. bOPV1/ IPV1 ü ü ü ü ü ü 7. PCV1 ü ü ü ü ü ü 8. DPT2 ü ü ü ü ü 9 HIB2 ü ü ü ü ü 10. HBV3 ü ü ü ü ü 11. bOPV2/ IPV2 ü ü ü ü ü 12. PCV2 ü ü ü ü ü 13. DPT3 ü ü ü ü 14. HIB3 ü ü ü ü 15. HBV4 ü ü ü ü 16. bOPV3/ IPV3 ü ü ü ü 17. PCV3 ü ü ü ü 18. Measles1, MR1, MMR1 ü ü ü 19. Measles 2, MR2, MMR2 ü CHECKLIST 1.3 (1/4) Screening, management and prevention of diarrhoea: interview with the caregiver QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Age of the child (in months) 2. Does the child have diarrhoea? If “No”, skip to Question 11 3. Did the health worker: a. Ask how long the child has had diarrhoea? b. Ask whether the child has bloody diarrhoea? 4. Is there blood in your child’s diarrhoea? If “No”, skip to Question 6 5. Did the health worker give or prescribe antibiotics? 2 6. Did the health worker: a. Give or prescribe oral rehydration salts (ORS) or recommended home fluids (RHF)? b. Give or prescribe zinc? 1 c. Provide counselling or advice to give extra fluids (longer and more frequent breastfeeds, ORS or RHF) and continued feeding? d. Give or prescribe a multivitamin? e. Give or prescribe antibiotics? 7. Summary: Was the child with watery diarrhoea managed correctly? Answer “Yes”, if Question 6.a–6.c = “Yes” and Questions 4, 6.d and 6.e = “No” 8. Has your child had diarrhoea for more than 14 days? If “No”, skip to Question 10 9. Summary: Was the child with diarrhoea for more than 14 days managed correctly? Answer “Yes”, if Question 6.a–6.d = “Yes”and Question 6.e = “No” 10. Did the health worker tell you when to bring the child back? CHECKLIST 1.3 (2/4) 16 CHECKLIST 1.3 17 CHECKLIST 1.3 (2/4) QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 11. What is the main source of drinking-water for the members of your household? Write “Yes” for the main source of water. a. Piped water into dwelling, yard or plot b. Public tap or standpipe c. Protected well or protected spring or protected rainwater harvesting d. Unprotected well or unprotected spring or unprotected rainwater harvesting e. Bottled water or sachet water, or cart with small tank, or drum, or tanker trunk f. Surface water (river, dam, lake, pond, stream, canal, irrigation channel) g. Other, please specify: ................................................................................................................... List: 12. If the main water source is not on the premises, how long does it take to go there, collect water and come back? (in minutes) Mean: Range: 13. Do you treat your water in any way to make it safer to drink? If “No”, skip to Question 15 14. What do you usually do to the water to make it safer to drink? Please indicate how you make your water safer to drink – boiling, adding chlorine, filtering, etc. List: 15. What kind of toilet facility do members of your household usually use? Write “Yes” for the one they usually use. a. Flush toilet to piped sewer system, septic tank or pit latrine b. Flush toilet to unknown place c. Flush toilet to open drain, elsewhere d. Pour flush latrine CHECKLIST 1.3 CHECKLIST 1.3 (4/4) CHECKLIST 1.3 (3/4) QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 e. Ventilated improved latrine/simple pit latrine with slab f. Composting toilet g. Pit latrine without slab/open pit, bucket latrine, hanging toilet h. Bush or open field 16. Do you share this toilet facility with other households? If “No”, skip to Question 18 17. How many households share this facility? Mean: Range: 18. The last time your child passed stools, what was done to dispose of the stools? a. Child used toilet/latrine b. Put/rinsed into toilet or latrine c. Put/rinsed into drain or ditch d. Thrown into garbage e. Buried f. Left in the open g. Other, please specify: h. Do not know 19. Are there handwashing facilities in your household (e.g. sink with water, tap with water, pot with water)? If “No”, skip to Question 21 20. Are soap and water currently available at the handwashing facilities? 18 CHECKLIST 1.3 19 CHECKLIST 1.3 (4/4) QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 21. Did any health worker counsel you on any of the following practices to reduce the risk of waterborne diseases today? a. Upgrading to a piped or protected water source b. Transporting and storing water safely c. Disinfecting water properly (boiling, other) d. Washing hands before preparing food and eating e. Washing hands with soap f. Washing hands before touching the child * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row. BCG, bacille Calmette-Guérin (vaccine); bOPV, bivalent oral poliovirus vaccine; DPT, diphtheria–pertussis–tetanus (vaccine); HBV, hepatitis B vaccine; Hib, Haemophilus influenza type b (vaccine); IPV, inactivated poliovirus vaccine; MMR, measles–mumps–rubella (vaccine); MR, measles–rubella (vaccine); PCV, pneumococcal vaccine; RHF, recommended home fluid 1. Zinc supplementation: elemental zinc 10 mg/day for infants < 6 months and 20 mg/day for children ≥ 6 months, for 14 days. 2. Ciprofloxacin for three days at an oral dose of 15 mg/kg. Ceftriaxone should be given as a second-line treatment in severely ill children where local antimicrobial sensitivity is not known. CHECKLIST 1.3 CHECKLIST 1.4 (1/2) Screening and management of cough and difficulty breathing: interview with the caregiver QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Age of the child (in months) 2. Does the child have cough or difficulty breathing? If “No”, skip to Question 4 3. Did the health worker: a. Ask whether your child had cough? b. Ask whether your child had wheezing? c. Ask for how long the child has had cough or wheezing? 4. Does your child have cough and wheezing, or wheezing alone? If “No”, skip to Question 8 5. Did the health worker: a. Give your child a trial 1 of an inhaled puffer or nebulizer? b. Give you an inhaled puffer to try at home for 5 days or advise you to come back to use the nebulizer? 6. Has your child had cough or wheezing for > 14 days? If “No”, skip to Question 8 7. Did the health worker refer your child for further assessment of tuberculosis or asthma? 8. Did the health worker give or prescribe one or more antibiotics? If “No”, skip to Question 9 a. Did the health worker tell you why antibiotics were given? 9. Did the health worker tell you when to bring the child back? CHECKLIST 1.4 (2/2) 20 CHECKLIST 1.4 21 CHECKLIST 1.4 (2/2) QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 10. Does anyone do any of the following inside your house: a. Smoke? b. Use wood for cooking or heating? c. Use charcoal for cooking or heating? d. Use dung for cooking or heating? e. Use kerosene for lighting? 11. Did the health worker give you counselling or advice to reduce indoor air pollution including: a. Eliminating smoking indoors? b. Changing cooking fuel? c. Cooking outside? d. Improving household ventilation? e. Switching to alternative sources for lighting? * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row. 1. Trial for up to three times 15–20 minutes apart if wheezing is present with either fast breathing or chest in-drawing: After trials, count the breaths, look for chest in-drawing again, and then classify. CHECKLIST 1.4 CHECKLIST 1.5 Screening and management of fever: interview with the caregiver QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Age of the child (in months) 2. Does the child have a fever (as reported by caregiver or with temperature 37.5 °C or above)? If “No”, skip to Checklist 1.6 3. Did the health worker ask how many days the child had a fever? 4. Did your child have a positive test for malaria? If “No”, skip to Question 6 5. Did the health worker: a. Give or prescribe an antimalarial medicine? b. Explain when you should bring the child back? c. Give you advice on how to prevent malaria? 6. Does your child have: a. An infection or rash on the skin? b. A painful ear and/or discharge from the ear? c. A red and sore throat? d. A red and sticky eye? 7. Did the health worker give or prescribe one or more antibiotics? If “No”, skip to Question 8 a. Did the health worker tell you why antibiotics were given? 8. Did the health worker explain when you should bring your child back? * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row. CHECKLIST 1.6 22 CHECKLIST 1.5 23 CHECKLIST 1.6 Screening and management of HIV: interview with the caregiver QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Age of the child (in months) 2. Have you ever been tested for HIV? If “No”, skip to Checklist 1.7 3. Are you HIV positive? If “No”, skip to Checklist 1.7 4. Has your child ever been tested for HIV? If “Yes”, skip to Question 6 5. Has your child been referred for HIV testing and management? 6. Is your child HIV positive? If “No” or “DK”, skip to Checklist 1.7 7. Did the health worker: a. Give or prescribe antiretroviral therapy (ART) treatment? (continued or new) b. Give or prescribe co-trimoxazole prophylaxis? (continued or new) c. Assess your child’s feeding and give advice or counselling on feeding? d. Give advice on home care? e. Give advice on when to return for follow-up? f. Give advice on next referral for higher-level assessment and management? * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row. CHECKLIST 1.6 CHECKLIST 1.7 (1/2) CHECKLIST 1.7 (2/2) Screening and management of injuries, abuse and neglect: interview with the caregiver QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Age of the child (in months) 2. Has your child ever suffered one or more injuries that required you to seek medical attention? If “No”, skip to Question 7 3. How many injuries has your child had in the past 12 months? n ≥ 1 4. What was the cause(s) of the child’s most recent injury? Answer “Yes” for all that apply a. Road traffic injury b. Fall c. Blunt trauma (being struck by a person or object) d. Burn e. Poisoning f. Electric shock g. Water related h. Animal bite i. Human bite j. Other, please specify: ................................................................................................................... List: 5. What was the nature of the injury? a. Fracture b. Laceration or cut c. Joint dislocation d. Contusion e. Concussion 24 CHECKLIST 1.7 25 CHECKLIST 1.7 (2/2) QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no) or DK (do not know) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 f. Burns g. Other, please specify: ................................................................................................................... List: 6. Did any health worker counsel you on preventing injuries in the future? 7. Please give examples of how you can prevent your child from being injured in the future. List: 8. Summary: Does the caregiver know at least three age-appropriate strategies to prevent the child being injured? 1 9. Please tell me what you or any other adult in your household has used to discipline your child in the past month. Answer “Yes” for all that apply a. Shook the child b. Shouted, yelled or screamed at the child c. Spanked, hit or slapped the child on the bottom with bare hand d. Slapped or hit the child with something like a hairbrush, stick, belt or other hard object e. Hit or slapped the child on the face, head or ears f. Hit or slapped the child on the hand, arm or leg g. Beat the child – hitting the child repeatedly as hard as one can * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row. 1. Age-appropriate strategies for preventing accidents and injuries, by age (see the summary table on next page). CHECKLIST 1.7 26 Age-appropriate strategies for preventing accidents and injuries, by age From birth to 9 months From 9 to 36 months 1. Provide adequate head control (birth to 14 weeks). Keep sharp and small objects and long strings out of reach. 2. Clothe appropriately for the climate. Observe the child at all times near water, fire, stairs, windows, vehicles, animals. 3. Never leave infant unattended on high or hot surfaces. Find safe places to play (do not allow the child to play on the road). 4. Ensure blankets are away from the child’s mouth and nose to avoid suffocation. Cut food into small enough pieces for a child’s mouth. 5. Avoid soft mattresses. Do not give hard food (such as nuts). 6. Perform good hygiene. 7. Sleep under insecticide-treated bed nets (malaria-endemic areas). 8. No parental smoking/indoor air pollution. Source: Wijnhoven T, de Onis M, Onyango O, Wang T et al. Assessment of gross motor development in the WHO multicenter growth reference study. Food Nutr Bull. 2004; 25(1)(Supp 1):S31–45 (https://journals.sagepub.com/doi/pdf/10.1177/15648265040251S106). CHECKLIST 1.8 (1/3) 27 CHECKLIST 1.8 (1/3) Early child development: interview with the caregiver QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no), DK (do not know) or NA (not applicable) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Age of the child (in months) 2. Has your child been diagnosed with any of the following? a. Visual impairment or blindness b. Hearing impairment or deafness c. Cerebral palsy d. Attention deficit hyperactivity disorder (ADHD) e. Autism spectrum disorder (ASD) f. Cleft lip or palate g. Spina bifida h. Club foot i. Down syndrome (trisomy 21) j. Physical deformity, please specify: k. Other developmental or chronic health problem, please specify: ..................................................................................................................................... 3. Summary: Has the child been diagnosed with at least one developmental or chronic health problem? Answer “Yes”, if at least one problem in Questions 2.a–2.k = “Yes”. If “No”, skip to Question 8 4. Does this problem impair your child's ability to do routine age- appropriate things (e.g. eat, move, sit, play, communicate, make eye contact)? 5. Is your child receiving regular therapy by a health professional for this problem inside or outside of the home? CHECKLIST 1.8 CHECKLIST 1.8 (2/3) CHECKLIST 1.8 (3/3) QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no), DK (do not know) or NA (not applicable) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 6. Is your child receiving modified educational methods, classes or compensations to improve social interactions and learning? 7. Have you made modifications in the household to manage this problem including special equipment or methods to help with movement, eating or behaviour? 8. Comparing your child to other children of the same age, do you have any concerns about how your child: a. Talks and makes speech sounds? b. Understands what you say? c. Uses his or her hands or fingers to do things? d. Uses his or her arms or legs? e. Behaves? f. Gets along with others? g. Learns to do things for himself or herself? h. Learns preschool or school skills? i. Any other concerns? Please specify: 9. Summary: Does the caregiver have at least one developmental concern? Answer “Yes”, if at least one concern in Questions 8.a–8.i = “Yes”. If “No”, skip to Question 12 10. Did the health worker ask whether you have any developmental concerns about your child today? 11. Did the health worker or another staff person at the facility refer the child for further developmental assessment or action to address your concern? 28 CHECKLIST 1.8 29 CHECKLIST 1.8 (3/3) QUESTION Ask the caregiver. Answer the questions with: Y (yes), N (no), DK (do not know) or NA (not applicable) Child number Summary n / Total* (%) CommentsSick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 12. Can you tell me what you can do to promote your child’s development? 13. Summary: Does the caregiver know at least three age-appropriate ways to promote childhood development? 1 14 Did the health worker or other staff person at the facility ask about the child’s involvement in playgroups and/or early child education? 15. Did the health worker or other staff person at the facility counsel you on the importance of playgroups/early child education – and on how to improve support? 16. Did the health worker or other staff person ask what you do at home to support your child to: a. Read? b. Play? c. Communicate with others? 17. Did the health worker counsel you on the importance of ensuring enough time with adults in the home to encourage reading, play and communication? * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row. 1. Age-appropriate strategies to promote child development (see the summary table on next page). CHECKLIST 1.8 30 Age-appropriate strategies to promote child development Age group Strategies to promote child development 1. From birth to 9 months » Stimulate the child by smiling, touching, talking and laughing. » Imitate child's movements and actions so child is in control. » Read out loud to child. » Avoid screen time and gadget use. 2. After 14 weeks to 9 months Above, plus: » Engage in interactive play. » Use child’s name and encourage response. » Name things and people. » Encourage sitting – ensure child can sit properly. » Encourage movement including crawling and walking – ensure there is no weakness or stiffness in limbs. » Look for any problems with seeing or hearing. 3. After 9 months Above, plus: » Talk to the child while maintaining eye contact and encourage them to sit still during a meal. » Promote counting or comparing things, teaching songs, playing games, reading books and telling stories. » Introduce toys for play such as blocks, pots and pans. » Spend adequate time with the child and do not leave them alone for too long. » Look for any problems with seeing or hearing. » Avoid screen time and gadget use. 4. 12–15 months Above, plus: » Ensure the child begins to walk – note continued crawling. » Ensure the child can say single words such as “mama” or “dada”. 5. 18–24 months Above, plus: » Ensure child can walk up steps. » Seek care if the child is learning to talk later than other children or having trouble speaking. » Encourage talking and communicating. 6. 24–36 months Above, plus: » Seek care if the child is not able to jump up or move appropriately. » Seek care if the child is not playing with other children or with toys. » Ask the child to name things and to count. » Compare and match colours and objects. » Reinforce and encourage correct speech and conversation. Source: Care for child development: improving the care of young children. Geneva: World Health Organization; 2012 (https://apps.who.int/iris/handle/10665/75149). 31 2. Chart review and re-examination of sick children after interview After the caretaker interview, sick and well children have their child health card or record reviewed for basic health screening. The five sick children then undergo a record review and re-examination. Case records and child health cards are used to determine the health worker’s findings for each clinical assessment task. INSTRUCTIONS 1. At the end of the exit interview, ask the mother or caregiver whether you can review the child’s records and re-examine the sick child. 2. Use Checklist 2.1 to review the child health cards or records of all sick and well children. 3. Use Checklist 2.2 to record agreement between the re-examination (RE) findings and the case record completed by the health worker. To conduct the re-examination, perform a complete IMCI history (asking questions to the mother) and examination for each child. For each RE area, record and compare the total number of assessment findings or screening tasks (“No“) with those in the case notes for each child (n/N). If nothing is recorded, write NR (not recorded). 4. Summarize the data in Checklist 2.2 in the columns at the end of each row. “Missed” (second column from the right) is the total number of responses for which the RE = “Yes” and the health worker has recorded N or NR. Missed means that a positive symptom or sign was present but not recorded by the health worker. If there are no positive symptoms or signs present, write “0”. “Agreement” (last column) is the total number of responses for which the health worker recorded findings that match those of the re-examination. When nothing is recorded in the record (NR), Agreement = “No”. Complete this column for all children receiving a re-examination. 5. If the child has been wrongly classified or the treatment is inappropriate, ask to speak to the health worker privately. Explain the problem and suggest an alternate classification and treatment approach. CHECKLIST 2.2 (1/4) Basic health screening: sick and well children QUESTION Use the child’s health card or record. Answer the questions with available data, or with Y (yes) or N (no) Child number Summary n / Total* (%) Sick-child register Well-child register 1 2 3 4 5 6 7 8 9 10 1. Child’s name 2. Age of the child (in months) 3. Which of the following were recorded for this visit: a. Temperature? b. Respiratory rate? c. Weight? d. Height? e. Weight-for-age percentile or z-score? f. Length/height-for-age percentile or z-score? g. Weight-for-length/height percentile or z-score? h. Mid-upper-arm circumference (MUAC) for children > 6 months (m)? N = (children > 6 m) 4. Summary: Are all growth measurements recorded? Answer “Yes”, if Questions 3.e–3.g all have a percentile or z-score entered, OR if Questions 3.e and 3.f have a percentile or z-score recorded and Questions 3.h = “Yes”. * ”n“ = total number of “Yes“ responses unless otherwise specified; ”Total“ = total number of children reviewed in each row. CHECKLIST 2.1 32 CHECKLIST 2.1 33 CHECKLIST 2.2 (1/4) Chart review and re-examination of the sick child CLINICAL ASSESSMENT Use the child’s record or chart to enter the health worker (HW) clinical assessment findings for each sick child whose caregiver was interviewed. Re-examine the child to complete the re-examination (RE). Answer the questions with: Y (yes), N (no) or NR (not recorded) Child number Missed (n/N)* Agreement (n/5)** 1 2 3 4 5 HW RE HW RE HW RE HW RE HW RE 1. Age of the child (in months) If the child is > 2 months, skip to Question 3 2. If the child is from 0 to 2 months, were the following danger signs present: a. Poor feeding? b. Movement only when stimulated or no movement? c. Fast breathing (> 60/min), severe chest in-drawing? d. Low temperature (< 35.5 °C) or fever (≥ 37.5 °C)? e. Convulsions? 3. If the child is from 2 months to 3 years, were the following symptoms present: a. Inability to drink/breastfeed? b. Lethargy or unconsciousness? c. Vomiting everything? d. Convulsions? 4. For each child, are the HW and RE findings the same? 1 Answer “Yes”, if Questions 2.a–2.e or 3.a–3.d are all in agreement 1. 5. Does the child have diarrhoea? If “No”, skip to Question 7 a. For how long? b. Blood in the stool? c. Irritable or lethargic? d. Very sunken eyes? e. Skin pinch slow? f. Severe,2 some, or no dehydration? CHECKLIST 2.2 CHECKLIST 2.2 (2/4) CHECKLIST 2.2 (3/4) CLINICAL ASSESSMENT Use the child’s record or chart to enter the health worker (HW) clinical assessment findings for each sick child whose caregiver was interviewed. Re-examine the child to complete the re-examination (RE). Answer the questions with: Y (yes), N (no) or NR (not recorded) Child number Missed (n/N)* Agreement (n/5)** 1 2 3 4 5 HW RE HW RE HW RE HW RE HW RE 6. For each child, are the HW and RE findings the same? 1 Answer “Yes”, if Questions 5.a–5.f are all in agreement 2. 7. Does the child have cough or difficulty breathing? If “No”, skip to Question 9 a. For how long? (in days) b. Breaths per minute (count)? c. Fast breathing identified? d. Chest in-drawing? e. Stridor? f. Wheezing? g. Cough or wheezing longer than 14 days? 8. For each child, are the HW and RE findings the same? 1 Answer “Yes”, if Questions 7.a–7.g are all in agreement 3. 9. Does the child have a fever (temperature ≥ 37.5 °C)? If “No”, skip to Question 11 a. For how long? b. Stiff neck? c. Any bacterial source of infection (skin, throat, ear, eye, other)? d. Any skin rash? e. If malaria is suspected, was microscopy or rapid diagnostic testing (RDT) for malaria performed? f. If dengue is suspected, was RDT for dengue performed? 10. For each child, are the HW and RE findings the same? 1 Answer “Yes”, if Questions 9.a–9.f are all in agreement 4. 34 CHECKLIST 2.2 35 CHECKLIST 2.2 (3/4) CLINICAL ASSESSMENT Use the child’s record or chart to enter the health worker (HW) clinical assessment findings for each sick child whose caregiver was interviewed. Re-examine the child to complete the re-examination (RE). Answer the questions with: Y (yes), N (no) or NR (not recorded) Child number Missed (n/N)* Agreement (n/5)** 1 2 3 4 5 HW RE HW RE HW RE HW RE HW RE 11. Does the child have any of the following markers of malnutrition? a. Weight-for-age: low (< –2 SD) or very low (< –3 SD)? b. Weight-for-height: low (< –2 SD or MUAC = 115–125 mm) or very low (< –3 SD or MUAC <115 mm) or high (> +2 z-score)? c. Height-for-age: low (< –2 SD) or very low (< –3 SD)? d. Some or severe palmar pallor, or anaemia on blood tests? e. Oedema of both feet? f. Able to breastfeed or eat ready-to-use therapeutic foods (RUTF)? g. Exposure history to tuberculosis (TB) or HIV? h. Confirmed TB by (chest) X-rays or other screening methods? i. Confirmed HIV? j. Breastfeeding or complementary feeding problem? 12. For each child, are the HW and RE findings the same? 1 Answer “Yes”, if Questions 11.a–11.j are all in agreement 5. 13. Is the child's mother HIV positive? 6. 14. Is the child HIV positive? 7. 15. Are there any clinical conditions associated with maltreatment? If “Yes”, list the signs.3 16. CLASSIFICATION(S) — Use IMCI ◊ chart booklet classifications. Child may have one or more classifications. a. Classification 1 – Please specify: .................................................................................. b. Classification 2 – Please specify: .................................................................................. c. Classification 3 – Please specify: .................................................................................. d. Classification 4 – Please specify: .................................................................................. CHECKLIST 2.2 CHECKLIST 2.2 (4/4) CLINICAL ASSESSMENT Use the child’s record or chart to enter the health worker (HW) clinical assessment findings for each sick child whose caregiver was interviewed. Re-examine the child to complete the re-examination (RE). Answer the questions with: Y (yes), N (no) or NR (not recorded) Child number Missed (n/N)* Agreement (n/5)** 1 2 3 4 5 HW RE HW RE HW RE HW RE HW RE 17. For each child, are the HW and RE findings the same? 1 Answer “Yes”, if all classifications above are in agreement 8. 18. TREATMENT(S) — Use IMCI chart booklet classifications Child may have one or more classifications. a. Treatment 1 – Please specify: ........................................................................................... b. Treatment 2 – Please specify: ........................................................................................... c. Treatment 3 – Please specify: ........................................................................................... d. Treatment 4 – Please specify: ........................................................................................... 19. For each child, are the HW and RE findings the same? 1 Answer “Yes”, if all classifications above are in agreement 9. 20. OVERALL AGREEMENT — Total possible score = 45 (9 x 5) ∑ n / 45 (%) IMCI, Integrated Management of Childhood Illness; MUAC,mid-upper-arm circumference; SD, standard deviation * Missed, total number of responses for which RE = “Yes” and the HW has recorded “No” or “NR”. ** Agreement, total number of responses for which the HW-recorded findings match those of the RE. When nothing is recorded in the record (NR) agreement is “No”. 1. When nothing is recorded (NR), agreement is “No”. 2. Severe dehydration: child is lethargic or irritable, skin pinch is slow and eyes are sunken. 3. Clinical signs of maltreatment: Physical abuse Bruises, lacerations, abrasions, scars, bites or fractures; thermal or cold injuries (burns); head (intracranial) or spinal injury. Injuries or harm Poisoning; non-fatal submersion injury (drowning); unusual attendance at medical services; fabricated or induced illness. Sexual abuse Ano-genital signs and symptoms; sexually transmitted infections. Signs of neglect Basic needs not provided; malnutrition; signs of delayed treatment or lack of care. Emotional change Parent reports: marked change in behaviour or emotional state; recurrent nightmares containing similar themes; extreme distress; oppositional behaviour. 36 CHECKLIST 2.2 37 3. Observations of environmental hygiene and promotional materials in outpatient clinics INSTRUCTIONS 1. Observe handwashing facilities and toilets for patients and supplies and equipment in outpatient well- and sick-child visit rooms, vaccination rooms and treatment rooms. 2. Complete Checklist 3. 3. For each aspect of environmental hygiene assessed, record the total number of observations (N) and of these, how many meet the criteria asked (n). 4. Give feedback to staff at the end of the review on areas for improvement. CHECKLIST 3 (1/3) Environmental hygiene and promotional materials QUESTION Answer the questions with Y (yes), N (no) or enter a number Well child Sick child Screening Vaccine Treatment Breast- feeding Total Comments 1. What is the total number of rooms (R)? Of these, how many: R = a. Have at least one sink for washing hands available for use in the room? 1 n / R = b. Have all surfaces free of clutter? n / R = c. Have clean thermometers and stethoscopes used for each patient? 2 n / R = d. Have at least one source of safe drinking- water for mixing ORS or RUTF (potable tap water, potable well water, boiled water, bottled water)? n / R = e. Have NO infant formula and milk formula company materials visible (posters, brochures, stickers, painted walls, on electronic media/ public Wi-Fi, etc.)? n / R = f. Have facility orders prohibiting use of infant formula or milk formula company products visibly posted in the area or available on electronic media/public Wi-Fi? n / R = 2. What is the total number of sinks (S)? Of these, how many: 3 S = a. Are clean? n / S = b. Have continuous clean, running water? 4 n / S = c. Have soap available? 5 n / S = d. Have single-use towels or hand dryers available? n / S = CHECKLIST 3 (2/3) 38 CHECKLIST 3 39 CHECKLIST 3 (2/3) QUESTION Answer the questions with Y (yes), N (no) or enter a number Well child Sick child Screening Vaccine Treatment Breast- feeding Total Comments 3. Summary: How many of the rooms have adequate sink handwashing facilities available? Adequate means that the room has at least one sink and Questions 2a–2d = “Yes” for all sinks. n / R = 4. How many rooms have at least one bottle of alcohol gel or hand rub available for use in the room n / R = 5. Summary: How many of the rooms have adequate sink handwashing facilities AND alcohol gel or hand rub available in the room? Answer “Yes” if Questions 3 and 5 = “Yes” n / R = 6. What is the total number of toilets for client (T) use? Of these, how many: T = a. Are functioning (including not blocked and not locked)? n / T = b. Are clean? n / T = c. Are designated for women and girls and provide facilities to manage menstrual hygiene needs? n / T = d. Meet the needs of people with reduced mobility/are wheelchair accessible? n / T = 7. What is the total number of toilets for staff (TS) use? Of these, how many: TS = a. Are functioning (including not blocked)? n / TS = b. Are clean? n / TS = CHECKLIST 3 CHECKLIST 3 (3/3) QUESTION Answer the questions with Y (yes), N (no) or enter a number Well child Sick child Screening Vaccine Treatment Breast- feeding Total Comments 8. How many dedicated sharps containers (SC) are available? Of these, how many: SC a. Are made of puncture-proof material (thick plastic or metal with no punctures/holes)? n / SC = b. Are not above the fill line? n / SC = c. Have lids that can be closed? n / SC = 9. How many medical/infectious waste containers (MWC) are available? Of these, how many: MWC a. Have lids on? n / MWC = b. Are not overflowing? n / MWC = c. Have a foot pedal? n / MWC = 10. How many general waste containers (GWC) are available? Of these, how many: GWC a. Have lids on? n / GWC = b. Are not overflowing? n / GWC = c. Have a foot pedal? n / GWC = ORS, oral rehydratation salts; RUTF, ready-to-use therapeutic food 1. If more than one room is available in a category, report availability in each room separately. Note if alcohol gel or hand rub is available for staff use but not for use by patients and families. 2. Separate equipment dedicated to each patient, or supplies for cleaning instruments available. 3. Standard for these questions provided by: Hand hygiene self-assessment framework. Geneva: World Health Organization; 2010 (https://www.who.int/publications/m/item/hand-hygiene- self-assessment-framework-2010). 4. A water supply that is either piped or from onsite storage, with appropriate disinfection, meeting appropriate safety standards for microbial and chemical contamination. 5. Soap, detergent-based products that contain no added antimicrobial agents or may contain these solely as preservatives. It may be in various forms including bar soap, tissue, leaf and liquid preparations. 40 CHECKLIST 3 41 4. Review of availability of essential medicines and supplies for child health services at outpatient clinics INSTRUCTIONS 1. Review the list of medicines and supplies by direct observation. Staff who work in outpatient child health clinics are often familiar with the availability of essential medicines, equipment and supplies. They can help identify where medicines and supplies are stored and answer key questions. 2. If staff are unsure of the status of some medicines or supplies, determine who should be consulted to determine the status. This may include staff from the pharmacy. 3. Complete Checklist 4. » The WHO definition of “normal storage conditions” is: “storage in dry, well-ventilated premises at temperatures of 15–25 °C or, depending on climatic conditions, up to 30 °C”. » “Functional” means that the equipment or device can be used effectively on the day of the review – it should not be broken, have missing parts or have any other defect that limits its effectiveness. » Stock records allow quantity of available stock to be recorded and monitored. They may be electronic or paper-based. » “Availability of medicines and supplies”: estimate the number of days without adequate amounts of stock or equipment in the previous 12 months (360 days). Inadequate amount of stock or equipment includes stock-outs (none available) and reduced quantities that result in routine practice standards not being met. If records are not available, ask staff to estimate the total number of days in the previous 12 months the item was not available, with one month equal to approximately 30 days. If no stock-outs or reduced availability, enter “0”. CHECKLIST 4 (1/4) Review of availability, storage conditions and validity of essential medicines and supplies for child health services at outpatient clinics DRUG OR SUPPLY Available on the day of the review Answer Y (Yes) or N (No) Stock condition Check (ü) all that apply Stock records Answer Y (Yes) or N (No) Number of days in the previous 12 months without an adequate amount of stock/functional equipment All criteria met Answer Y (yes) only if: A = Y, B = ü, C = Y and D = 0 A B C D 1. Vitamin K £ Normal storage £ Protected from light £ No expired drugs 2. Hepatitis B (HepB) vaccine £ 2 °C–8 °C £ No expired drugs 3. BCG (bacille Calmette-Guérin) vaccine £ 2 °C–8 °C £ No expired drugs 4. bivalent oral poliovirus (bOPV) vaccine £ – 15 °C–25 °C £ No expired drugs 5. Inactivated poliovirus (IPV) vaccine £ 2 °C–8 °C £ No expired drugs 6. Toxoid pneumococcal (PCV) vaccine £ 2 °C–8 °C £ No expired drugs 7. Measles vaccine £ 2 °C–8 °C £ No expired drugs 8. Pentavalent vaccine or individual vaccines for DTwP–Hib–HepB £ 2 °C–8 °C £ No expired drugs 9. Measles or measles–mumps–rubella (MMR) vaccine £ 2 °C–8 °C £ No expired drugs CHECKLIST 4 (2/4) 42 CHECKLIST 4 43 CHECKLIST 4 (2/4) DRUG OR SUPPLY Available on the day of the review Answer Y (Yes) or N (No) Stock condition Check (ü) all that apply Stock records Answer Y (Yes) or N (No) Number of days in the previous 12 months without an adequate amount of stock/functional equipment All criteria met Answer Y (yes) only if: A = Y, B = ü, C = Y and D = 0 A B C D 10. Vitamin A (100 000 IU and 200 000 IU) £ Normal storage £ Protected from light £ No expired drugs 11. Mebendazole (500 mg) £ Normal storage £ Protected from light £ No expired drugs 12. Iron (syrup) £ Normal storage £ Protected from light £ No expired drugs 13. Oral rehydration salts (ORS) £ Normal storage £ No expired drugs 14. Injectable gentamycin for management of infant sepsis £ Normal storage £ Protected from light £ No expired drugs 15. Antibiotics (e.g. amoxicillin) for management of pneumonia £ Normal storage £ Protected from light £ No expired drugs 16. Co-trimoxazole (for prevention of complications due to HIV) £ Normal storage £ Protected from light £ No expired drugs 17. Ciprofloxacin or ceftriaxone (for management of dysentery) £ Normal storage £ Protected from light £ No expired drugs CHECKLIST 4 CHECKLIST 4 (3/4) DRUG OR SUPPLY Available on the day of the review Answer Y (Yes) or N (No) Stock condition Check (ü) all that apply Stock records Answer Y (Yes) or N (No) Number of days in the previous 12 months without an adequate amount of stock/functional equipment All criteria met Answer Y (yes) only if: A = Y, B = ü, C = Y and D = 0 A B C D 18. Antiretroviral (HIV) £ Normal storage £ Protected from light £ No expired drugs 19. Oral antimalarial £ Normal storage £ Protected from light £ No expired drugs 20. Artesunate or quinine for severe malaria £ Normal storage £ Protected from light £ No expired drugs 21. Erythromycin/tetracycline eye ointment £ Normal storage £ Protected from light £ No expired drugs 22. Glucose solution £ Normal storage £ No expired drugs 23. Zinc drops/syrup £ Normal storage £ No expired drugs 24. Ready-to-use therapeutic food (RUTF) 1 formulations £ Normal storage £ No expired drugs 25. Micronutrient powders £ Normal storage £ No expired drugs 26. Bronchodilator (salbutamol) £ Normal storage £ Protected from light £ No expired drugs CHECKLIST 4 (4/4) 44 CHECKLIST 4 45 CHECKLIST 4 (4/4) DRUG OR SUPPLY Available on the day of the review Answer Y (Yes) or N (No) Stock condition Check (ü) all that apply Stock records Answer Y (Yes) or N (No) Number of days in the previous 12 months without an adequate amount of stock/functional equipment All criteria met Answer Y (yes) only if: A = Y, B = ü, C = Y and D = 0 A B C D 27. Inhaler/spacer for giving bronchodilator (sizes for different ages) £ Equipment functional 28. Ringers lactate IV £ Normal storage £ No expired drugs 29. Normal saline IV £ Normal storage £ No expired drugs 30. Syringes for giving IM medicines £ Normal storage 31. Syringes for giving vaccinations £ Normal storage 32. Functional autoclave or steam sterilizer £ Equipment functional 33. Timing devices for counting respiratory rate (wall clock, other) £ Equipment functional 34. Cups, spoons and water for giving ORS £ Equipment functional 35. Rapid diagnostic tests for malaria £ 2 °C –30 °C 36. Rapid diagnostic tests for dengue £ 2 °C –30 °C 37. Weighing scale(s) – non-standing infants £ Equipment functional 38. Weighing scale – standing infants and children £ Equipment functional 39. Mid-upper-arm circumference (MUAC) tape £ Equipment functional 40. Height–length boards £ Equipment functional 41. Growth charts £ In good condition DTwP, diphtheria-tetanus whole-cell pertussis; HepB, hepatitis B ; Hib, Haemophilus influenza type b; IM, intramuscular; IU, international unit; IV, intravenous; ORS, oral rehydration salts 1. Ready-to-use therapeutic foods (RUTFs) are high-energy, lipid-based spreads used in any cultural setting for the treatment of severe acute malnutrition. RUTF may be the sole source of food, except water and/or breast milk, during the period of use. RUTF must meet the specifications of the United Nations Children’s Fund Supply Catalog for therapeutic spreads (http:// www.supply.unicef.dk/catalogue/). CHECKLIST 4 46 Primary health care quality improvement guide — Module 3: Care for infants and young children 5. Review of policies, guidelines and standards for child health services INSTRUCTIONS 1. Acquire copies of facility policies, standards, guidelines or standard operating procedures (SOPs) listed in Checklist 5 and record those currently available. 2. Electronic files can be counted as available if they can be viewed. 3. Guidelines written in policy documents, clinical practice guides or flowcharts may be counted as available. 4. Verify whether staff have been oriented on and use written policies, standards, guidelines or SOPs. CH EC KL IS T 5 ( 1 /3 ) 47 CHECKLIST 5 (1/3) Review of policies, guidelines and standards for child health services at outpatient clinics POLICY AREA Does the facility have a written policy, standard, guidelines or SOPs? 1 (Y or N) Have staff been oriented on the policy, standard, guidelines or SOPs? 2 (Y or N) 1. Routine health screening conducted for all children in outpatient clinics (weighing and plotting on growth chart, temperature, counting respiratory rate, check for anaemia) 2. Routine breastfeeding screening for infants 0–24 months (exclusive breastfeeding for infants < 6 months, frequency of feeds, identify problems, observe practice) 3. Routine complementary feeding screening and counselling for children 6–24 months (food and fluids given, frequency of feeds, size of feeds) 4. Protocol for feeding counselling for children identified with feeding problems 5. Definition of severe acute malnutrition (SAM) and management protocol consistent with WHO standards (weight for height < –3 SD score of WHO reference or MUAC < 115 mm) 6. Definition of stunting and management protocol consistent with WHO standards (length/height-for-age < –2 SD of WHO reference) 7. Definition of undernutrition and management protocol consistent with WHO standards (weight-for-age < –2 SD WHO reference) 8. Clinical case definition of anaemia 9. Treatment protocol for management of anaemia with iron and mebendazole consistent with WHO standards 10. Integrated Management of Childhood Illness (IMCI) standards adopted and used in outpatient clinics a. For children from 2 months to 5 years b. For newborns from 0 to 2 months 11. Orders/regulations prohibiting use of infant formula and other linkages with milk formula companies 12. Accreditation and certification for the health facility include child health standards CHECKLIST 5 CHECKLIST 5 (2/3) CHECKLIST 5 (3/3) POLICY AREA Does the facility have a written policy, standard, guidelines or SOPs? 1 (Y or N) Have staff been oriented on the policy, standard, guidelines or SOPs? 2 (Y or N) 13. Protocols and standards for screening and management of the sick child are consistent with international and/or WHO standards: a. Danger signs for immediate referral b. Clinical assessment of dehydration c. ORS and zinc for the management of diarrhoea d. Assessment and management of bloody diarrhoea e. Assessment and management of persistent diarrhoea f. Clinical assessment of cough or difficult breathing g. Definition of elevated respiratory rate for newborns and children h. Assessment and management of wheezing i. Clinical assessment of fever (stiff neck; malaria, where endemic; other bacterial causes) j. Use of rapid diagnostic tests for malaria k. Use of rapid diagnostic tests for dengue l. First-line treatment for malaria m. Referral and pre-referral treatment of children with danger signs or very severe disease n. Screening and referral of children with suspected tuberculosis (TB) or HIV 14. Protocols for routine developmental screening, management and referral for all children 0–36 months (developmental milestones, movement, problems with vision or hearing, caregiver concerns) 15. Protocol for management and referral of children with suspicion of abuse or maltreatment at home 48 CHECKLIST 5 49 CHECKLIST 5 (3/3) POLICY AREA Does the facility have a written policy, standard, guidelines or SOPs? 1 (Y or N) Have staff been oriented on the policy, standard, guidelines or SOPs? 2 (Y or N) 16. Age-appropriate standards and/or counselling guidelines for preventing childhood unintentional injuries 17. Age-appropriate standards and/or counselling guidelines for activities to stimulate or foster learning in the home 18. Disability inclusion to support children or parents with a disability to access the health care they require 19. Infection control practices including: a. Handwashing practices b. Use of double gloves for high-risk cases c. Processing contaminated instruments d. Disinfection of surfaces, floors and other items e. Sharps and waste management f. Disinfection of equipment including stethoscopes and thermometers between patients 20. Patient–staff ratios for: a. Well-child clinics b. Sick-child clinics c. Vaccination clinics d. Outpatient treatment rooms MUAC, mid-upper-arm circumference; ORS, oral rehydratation salts; SD, standard deviation; SOP, standard operating procedure 1. Policies, standards or guidelines must be based on national standards. They can be written policy documents, standard operating procedures or clinical practice guidelines. 2. Answer ”Yes“ (Y) if all staff conducting outpatient clinics have been oriented about or routinely use the policy, standard or guidelines. CHECKLIST 5 50 Primary health care quality improvement guide — Module 3: Care for infants and young children 6. Register review − sick-child outpatient clinics INSTRUCTIONS 1. Review sick-child registers for three months in the previous year. 2. Count the total number of sick-child visits by diagnosis. Count visits based on individual entries in facility registers. Do not count monthly summaries already calculated from register data. 3. Compare child health data reported in the routine health management information system (HMIS) with facility register data for the same three months in the previous year and complete Checklist 6. Calculate a verification factor, which is the direct register count divided by the count reported in health information system data. This allows reported data to be validated against facility records. If significant differences are found, discuss possible reasons with facility staff. CH EC KL IS T 6 51 CHECKLIST 6 Validation of reported child health data using facility records Recount values from facility registers for three months in the previous year INDICATOR Number of cases of: Value in national HMIS Value in provincial HMIS (if applicable) Recount value from register or patient chart Verification factor (register/reported value) Remarks MONTH 1 1. Diarrhoea 2. Pneumonia 3. Viral fever 4. Malnutrition 5. Tuberculosis (TB) 6. Developmental problems MONTH 2 7. Diarrhoea 8. Pneumonia 9. Viral fever 10. Malnutrition 11. TB 12. Developmental problems MONTH 3 13. Diarrhoea 14. Pneumonia 15. Viral fever 16. Malnutrition 17. TB 18. Developmental problems HMIS, health management information system CHECKLIST 6 52 Primary health care quality improvement guide — Module 3: Care for infants and young children 7. Review child health training status of outpatient staff INSTRUCTIONS 1. Ask the facility or clinic manager to identify all staff working at the outpatient clinic on infant and child health care. List staff by title and category on Checklist 7. Ensure that only staff currently working are included. Do not include staff who have left the facility. Include all new and trainee staff if they are currently working. 2. Ask the facility or clinic manager, or individual staff, about the training they have received in the previous five years by type of training. Write Y (“Yes”) if training has been received. If a staff member has received a type of training more than once, count it only once. 3. Summarize findings at the bottom of the table. Record the total number of staff and the proportion who have received training by topic. Also, record the total number of staff by category (doctor, medical assistant, nurse/midwife or other) and for each the proportion that have received training by type. CH EC KL IS T 7 53 CHECKLIST 7 Staff training summary: well- and sick-child outpatient clinics Training or skills received in the previous five years STAFF BY TITLE AND CATEGORY TYPE OF TRAINING IMCI KMC/IYCF/ Nutrition HIV/TB ECD/childhood disability Injuries, abuse, maltreatment Other 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Total (%) 18. Total (%) doctors 19. Total (%) medical assistants 20. Total (%) nurses and/or midwives 21. Total (%) other ECD, early childhood development; IMCI, Integrated Management of Childhood Illness; IYCF, infant and young child feeding; KMC, Kangaroo Mother Care; TB, tuberculosis CHECKLIST 7 54 Primary health care quality improvement guide — Module 3: Care for infants and young children SECTION 2 Develop a facility action plan INSTRUCTIONS 1. Consolidate Checklists 1–7 onto flip-charts or one master set laid out on a table. 2. Review each checklist and identify strengths and areas for improvement. Additional areas for improvement identified that were not on the checklists can also be listed. 3. After discussion, agree on the two or three most important areas for improvement to address in the next three months. Enter these into Table 3. 4. For each area for improvement, identify the underlying reasons for the observed gap or problem. 5. For each underlying reason, identify actions that can be taken to address the issue, who is responsible and the timing. 6. Debrief with the facility director and available staff to discuss and eventually agree on the findings and the plan. 7. Leave a copy of the Facility Priority Actions with the facility director and staff, and decide when the plan will be reviewed and who will be responsible for conducting the review. If the assessment is part of an annual implementation review, keep Checklists 1–7 and Table 3 for review with the larger review team. 55 TABLE 3 Priority actions to improve child health services at outpatient clinics Facility name .................................................................................................................................................................................................. Priority area for improvement Underlying reasons Priority actions Person responsible Timing Status/ Date 1. CLINICAL PRACTICE (Checklists 1.1–1.8 and 2.2) 2. ENVIRONMENTAL HYGIENE AND PROMOTIONAL MATERIALS (Checklist 3) 3. ESSENTIAL MEDICINES AND SUPPLIES (Checklist 4) 4. POLICIES, GUIDELINES AND STANDARDS (Checklist 5) 5. FACILITY DATA (Checklist 6) 6. STAFF TRAINING (Checklist 7) 56 Primary health care quality improvement guide — Module 3: Care for infants and young children SECTION 3 Synthesize findings from a review of several facilities Conducted by the evaluation teams that have reviewed a sample of primary-care facilities. INSTRUCTIONS 1. Draw Checklists 1–7: Summary form for all health facilities on flip-chart paper and post on the wall (a total of seven summary checklists should be completed and posted on the wall). 2. Health facility evaluation teams record data on the summary forms; one column per facility. If there are more than 18 facilities, add extra columns on the flip-chart paper. Summarize data for Checklists 4, 5 and 6 as follows: » Checklist 4: Record “Yes” or “No” for all criteria met in the final column (medicines and supplies that are present, stored appropriately and have had 0 days stock-outs or reduced availability in the previous 12 months). » Checklist 5: Record “Yes” if written policies are available and staff have been oriented. » Checklist 6: Record the verification factor for each disease and month. 3. Tally data for all health facilities on the summary forms. 4. Calculate separate totals for each of the three main categories of facility (national and regional hospitals, first-level referral hospitals and first-level health facilities). 5. Using final summary data, teams discuss indicators and mark those that are low with a red marker and those that show progress with a green marker – Note: this should be locally adapted as per local practice. 6. Participants as a group walk between checklist summary sheets and identify strengths and priority areas for improvement. 7. Discuss findings and reach consensus on main findings. Note: all data should also be entered electronically. Standard Excel spreadsheet files are attached separately. CH EC KL IS TS 1 –7 ( 1 /2 ) 57 CHECKLISTS 1–7 (1/2) Summary form for all health facilities Checklist: ..................................................................................................................................................................................................................................................................... QUESTION Health facility number (1) Total By level 1 1 2 3 4 5 6 7 8 9 n / N (%) a, b or c 1. £ a. £ b. £ c. 2. £ a. £ b. £ c. 3. £ a. £ b. £ c. 4. £ a. £ b. £ c. 5. £ a. £ b. £ c. 6. £ a. £ b. £ c. 7. £ a. £ b. £ c. 8. £ a. £ b. £ c. 9. £ a. £ b. £ c. 10. £ a. £ b. £ c. 1. The health facility levels are: 1) national and regional hospitals; 2) first-level referral hospitals; and 3) first-level health facilities. Note: if there are more than 18 facilities, add extra columns. CHECKLISTS 1–7 Checklist: ..................................................................................................................................................................................................................................................................... QUESTION Health facility number (2) Total By level 1 10 11 12 13 14 15 16 17 18 n / N (%) a, b or c 1. £ a. £ b. £ c. 2. £ a. £ b. £ c. 3. £ a. £ b. £ c. 4. £ a. £ b. £ c. 5. £ a. £ b. £ c. 6. £ a. £ b. £ c. 7. £ a. £ b. £ c. 8. £ a. £ b. £ c. 9. £ a. £ b. £ c. 10. £ a. £ b. £ c. 1. The health facility levels are: 1) national and regional hospitals; 2) first-level referral hospitals; and 3) first-level health facilities. Note: if there are more than 18 facilities, add extra columns. CHECKLISTS 1–7 (2/2) 58 CHECKLISTS 1–7 59 SECTION 4 Review monitoring and evaluation data for child health Conducted by the evaluation teams that have reviewed a sample of primary-care facilities. INSTRUCTIONS 1. Draw the monitoring and evaluation tables on flip-chart paper and post on the wall, summarizing data for all health facilities combined. Data for Tables 4–7 should have been entered in advance (a total of four monitoring and evaluation summary sheets should be completed and posted on the wall. 2. Review data for each of the three main categories of the facility (national and regional hospitals, first- level referral hospitals and first-level health facilities). Note indicators that show large differences between levels and those low across most levels. 3. Using final summary data, teams discuss indicators and mark those that are low or have not improved over time with a red marker and those that show progress with a green marker. Note: this should be locally adapted to local practice. 4. Participants as a group walk between checklist summary sheets and identify strengths and priority areas for improvements. 5. Discuss findings and reach consensus on main findings. 60 Primary health care quality improvement guide — Module 3: Care for infants and young children TABLE 4 Benchmarks of scale-up readiness, 2023–2027 Note: review benchmarks annually to track progress with benchmarks scoring “No” and “Partial”, and to ensure that benchmarks that previously scored “Yes” have not changed. Level of facility: National .............................................................. Regional........................................................................ Provincial ........................................................................ BENCHMARK Status (“Yes”, “No”, “Partial“) Country target2023 2024 2025 2026 2027 1. Child health situation analysis conducted in the previous 5 years and used for strategic planning1 Yes 2. Child health action plan developed, costed and endorsed by the health ministry Yes 3. Detailed annual or biennial child health implementation plan developed and funded Yes 4. Child health technical working group formed and meeting regularly 2 Yes 5. Mechanism for monitoring and enforcing the International Code of Marketing of Breast-milk Substitutes functioning Yes 6. Child health focal person appointed in the health ministry Yes 7. Child health stakeholder group formed to engage key political leaders and champions and meeting regularly 3 Yes 8. Clinical child health outpatient protocols include core child health interventions based on international standards 4 Yes 9. Annual or biennial implementation reviews are conducted to inform development of implementation plans Yes 10. Mechanisms established to ensure that professional associations are supporting implementation of national child health policies Yes 11. Proportion of preventive and curative child health interventions included in pre-service training curricula: a) medical; b) nursing; and c) midwifery 4 100% for all 1. Situation analysis includes a review of trends in child morbidity and mortality and intervention coverage along the continuum of care; an analysis of child health equity for different populations and groups; and status of key systems inputs to support delivery of child health interventions. 2. Membership may include the health ministry’s public health divisions, paediatric decision-makers, professional associations, civil society organizations and development partners. Meeting frequency is recommended at least quarterly. 3. Membership may include policy-makers, legislators, health providers, health facility administrators, civil society leaders, development partners, media practitioners, academia and health professional associations. Meeting frequency is recommended at least quarterly. 4. Core interventions: Core intervention package. Manila: WHO Regional Office for the Western Pacific; 2017. Protocols and standards: WHO Guideline Review Committee approved recommendations. IMCI chart booklet. Geneva: World Health Organization; 2014. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses. Geneva: World Health Organization; 2013. 61 TABLE 5 Health facility child health standards, 2023–2027 Use facility summary forms to complete one table for all facilities combined. Note indicators where findings differ by facility level: 1) national and regional hospitals, 2) first-level referral hospitals, and 3) first-level health facilities. INDICATOR Data by year National target2023 2024 2025 2026 2027 1. For all children: a. Proportion with all growth measurements recorded b. Proportion < 6 months receiving breastfeeding screening c. Proportion 6–36 months receiving complementary feeding screening d. Proportion > 12 months leaving the facility fully immunized e. Proportion of caregivers counselled on how to prevent injury from common risks f. Proportion receiving developmental screening 2. For sick children: a. Proportion of children with diarrhoea treated correctly b. Proportion of children with cough or difficulty breathing treated correctly c. Proportion of children with fever treated correctly 3. Proportion of staff providing care at outpatient health facilities trained in primary health care for child health 90% 4. Proportion of health facilities with adequate handwashing resources available in all rooms 100% 5. Proportion of health facilities with no stock-outs of key medicines 100% (4.1–4.6. all 100%) a. Oral rehydration salts (ORS) solution 100% b. Zinc drops/syrup 100% c. Injectable antibiotic for severe disease 100% 62 Primary health care quality improvement guide — Module 3: Care for infants and young children INDICATOR Data by year National target2023 2024 2025 2026 2027 d. Oral antibiotic for pneumonia 100% e Oral antimalarial 100% f. Oral iron 100% 6. Proportion of health facility standards met by the facility 1 70% 1. Proportion of all questions (N = 17) that meet the target, expressed as n/17 (%). TABLE 5 Health facility child health standards, 2023–2027 (continued) 63 TABLE 6 Coverage indicators for child health interventions, 2023–2027 Use representative population-based surveys such as the Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) to periodically measure coverage. Present a summary of national data and disaggregate by administrative, geographic or other subgroups for subnational tracking and programme planning.1 Level of facility: National ............................................................................... Subnational area or group ..................................................................................................................................... COVERAGE MEASURE Data by survey year (Source) Fill in year National target ................. ................. ................. ................. ................. 1. Proportion of children with diarrhoea in the previous two weeks who sought care outside of the home from a primary-care facility 2. Proportion of children with diarrhoea in the previous two weeks receiving oral rehydration therapy (ORT) 3. Proportion of children with diarrhoea in the previous two weeks receiving ORT and zinc 4. Proportion of children with diarrhoea in the previous two weeks receiving increased fluids and continued feeding 5. Proportion of children with diarrhoea in the previous two weeks receiving antibiotics or other medicines or injections 6. Proportion of children with symptoms of acute respiratory infection (ARI) in the previous two weeks who sought care from a primary facility care facility 7. Proportion of children with malaria in the previous two weeks treated with an appropriate antimalarial 8. Proportion of children sleeping under an insecticide-treated bed net the previous night 9. Proportion of children 6–59 months who received vitamin A in the past six months 64 Primary health care quality improvement guide — Module 3: Care for infants and young children COVERAGE MEASURE Data by survey year (Source) Fill in year National target ................. ................. ................. ................. ................. 10. Proportion of children 0–6 months who are exclusively breastfed 11. Proportion of children 6–8 months who were breastfed and ate solid and semi-solid foods at least two times the day before 12. Percentage of children aged 6–36 months with whom an adult household member has engaged in four or more activities to promote learning and school readiness in the past three days 13. Percentage of children aged 1–5 years who experienced any violent discipline (psychological aggression and/or physical punishment) in the past month 14. Percentage of children aged 0–59 months left alone or in the care of another child under 10 years old in the past week 15. Percentage of children aged 36–59 months enrolled in some form of early childhood education programme 1. For survey methods and standard definitions of coverage indicators, see: http://www.dhsprogram.com/data/Data-Tools-and-Manuals.cfm and http://mics.unicef.org – including: https://data.unicef.org/topic/early-childhood-development/home-environment. TABLE 6 Coverage indicators for child health interventions, 2023–2027 (continued) 65 TABLE 7 Impact indicators for child health, 2023–2027 Use representative population-based surveys, such as the Demographic and Health Survey (DHS), Multiple Indicator Cluster Survey (MICS), civil registration and vital statistics (CRVS) data where available, valid and reliable. Modelled mortality data (Inter-agency Group for Child Mortality Estimation [IGME] and Child Health Epidemiology Reference Group [CHERG]) may be used to track trends. Routine data from HMIS may be used to track trends in prematurity and low birthweight. Present a summary of national data and disaggregate by administrative, geographic or other subgroups for subnational tracking and programme planning.1 Level of facility: National ............................................................................... Subnational area or group ..................................................................................................................................... MEASUREMENT Data by survey year (Source) Fill in year Country target ................. ................. ................. ................. ................. 1. Under-5 mortality rate (per 1000 live births) 2. Infant-mortality rate (per 1000 live births) 3. Proportional causes of death of children 1–59 months (5 years) a. Diarrhoea b. Pneumonia c. Injury 4. Prevalence of low birthweight (less than 2500 g) 5. Prevalence of low weight-for-length/height (z-score: –2 or less) 6. Prevalence of low length/height-for-age (z-score: –2 or less) 7. Prevalence of low weight-for-age (z-score –2 or less) 8. Prevalence of anaemia in children 6–59 months (Hg, 10 g/dL) 1. For survey methods and standard definitions of impact indicators, see: http://www.dhsprogram.com/data/Data-Tools-and-Manuals.cfm and http://mics.unicef.org. 66 Primary health care quality improvement guide — Module 3: Care for infants and young children SECTION 5 Use findings to develop an annual implementation plan for improving child health 1. Identify priority problems INSTRUCTIONS 1. Draw the following checklists and tables on flip-chart paper and post them on the wall: » Checklists 1 and 2 and Tables 5, 6, 7: Clinical practice » Checklist 3: Environmental hygiene and promotional materials » Checklist 4: Essential medicines and supplies » Checklist 5 and Table 4: National policies, guidelines and standards to support implementation » Checklist 6: Facility data » Checklist 7: Staff training 2. Draw Table 8 on flip-chart paper. 3. Review the findings from checklists and monitoring and evaluation tables – including differences between facility levels. Review the findings from Table 3. 4. Identify technical issues or gaps and underlying reasons for gaps. 5. Summarize the final list of prioritized areas for improvement to the group and ensure that there is consensus. Record prioritized areas in Table 8 under each relevant programme area. 67 TABLE 8 Synthesis of review findings: national sample of health facilities PROGRAMME AREA Strengths Priority areas for improvement Underlying reasons for gaps or problems 1. CLINICAL PRACTICE (Checklists 1, 2 and Tables 5, 6, 7) 2. ENVIRONMENTAL HYGIENE AND PROMOTIONAL MATERIALS (Checklist 3) 3. ESSENTIAL MEDICINES AND SUPPLIES (Checklist 4) 4. POLICIES, GUIDELINES AND STANDARDS (Checklist 5 and Table 4) 5. FACILITY DATA (Checklist 6) 6. STAFF TRAINING (Checklist 7) 68 Primary health care quality improvement guide — Module 3: Care for infants and young children 2. Develop an annual child health action plan INSTRUCTIONS 1. Draw Table 9 on flip-chart paper (see next page). 1. Review actions in the previous annual plan for the priority areas of improvement identified in Table 8. Review the findings from Table 3. 2. Review whether current actions need to be continued and brainstorm possible new actions to address the priority area for improvement. Base priority actions on underlying reasons for areas for improvement. Consider: » importance of improving child health clinical practice; » whether action can be taken with existing resources and personnel; and » whether action can be taken in the next three months (or for longer-term priorities, whether actions can begin within three months). 3. Write the agreed priority actions on the flip-chart. 69 TABLE 9 Annual action plan for improving child health at outpatient facilities PRIORITY ACTION Person responsible Time Estimated budget and source of funding 1. CLINICAL PRACTICE 2. ENVIRONMENTAL HYGIENE AND PROMOTIONAL MATERIALS 3. ESSENTIAL MEDICINES AND SUPPLIES 4. POLICIES, GUIDELINES AND STANDARDS 5. FACILITY DATA 6. STAFF TRAINING

74 Primary health care quality improvement guide — Module 3: Care for infants and young children

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 8 avril 2024

Source Organisation mondiale de la santé