Are children presenting with non-IMCI complaints at greater risk for suboptimal screening? An analysis of outpatient visits in Afghanistan

Objective: To determine if children presenting without complaints related to the Integrated Management of Childhood Illness (IMCI) are at greater risk for suboptimal screening for IMCI conditions Design: Cross-sectional study. Setting: Thirty-three provinces in Afghanistan. Participants: Observation of 3072 sick child visits selected by systematic random sampling. Main outcome measure(s): A 10 point IMCI assessment index. Results: One hundred and thirty-one (4.3%) of the 3072 sick child visits involved no IMCI-related complaints. The mean assessment index for all sick child visits was 4.81 (SD 2.41). Visits involving any IMCI-related complaint were associated with a 1.02 point higher mean assessment index than those without IMCI-related complaints (95% CI, 0.52-1.53; P < 0.001). After adjusting for relevant covariates including patient age, caretaker gender, provider type, provider gender, provider IMCI training status and IMCI guideline availability, we found that children with IMCI-related presenting complaints had a significantly better quality of IMCI screening, than those without IMCI presenting complaints (by 0.75 points; 95% CI, 0.25-1.26; P = 0.003) Conclusions: Our study indicates that children with non-IMCI presenting complaints are at greater risk of suboptimal screening compared to children with IMCI-related presenting complaints. The premise of IMCI is to routinely screen all children for conditions responsible for the major burden of childhood disease in countries like Afghanistan. The study illustrates an important finding that facility and provider capacity needs to be improved, particularly during training, supervision and guideline dissemination to ensure that all children receive routine screening for common IMCI conditions.