title: Why first-level health workers fail to follow guidelines for managing severe disease in children in the Coast Region, the United Republic of Tanzania.
abstract: OBJECTIVE
  To determine why health workers fail to follow integrated management of childhood illness (IMCI) guidelines for severely ill children at first-level outpatient health facilities in rural areas of the United Republic of Tanzania.
  
  
  METHODS
  Retrospective and prospective case reviews of severely ill children aged < 5 years were conducted at health facilities in four districts. We ascertained treatment and examined the characteristics associated with referral, conducted follow-up interviews with parents of severely ill children, and gave health workers questionnaires and interviews.
  
  
  RESULTS
  In total, 502 cases were reviewed at 62 facilities. Treatment with antimalarials and antibiotics was consistent with the diagnosis given by health workers. However, of 240 children classified as having 'very severe febrile disease', none received all IMCI-recommended therapies, and only 25% of severely ill children were referred. Lethargy and anaemia diagnoses were independently associated with referral. Most (91%) health workers indicated that certain severe conditions can be managed without referral.
  
  
  CONCLUSIONS
  The health workers surveyed rarely adhered to IMCI treatment and referral guidelines for children with severe illness. They administered therapy based on narrow diagnoses rather than IMCI classifications, disagreed with referral guidelines and often considered referral unnecessary. To improve implementation of IMCI, attention should focus on the reasons for health worker non-adherence.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, United States of America. nwalter@cdc.gov
authors.forename: Nicholas D
authors.initials: ND
authors.lastname: Walter
authors.forename: Thomas
authors.initials: T
authors.lastname: Lyimo
authors.forename: Jacek
authors.initials: J
authors.lastname: Skarbinski
authors.forename: Emmy
authors.initials: E
authors.lastname: Metta
authors.forename: Elizeus
authors.initials: E
authors.lastname: Kahigwa
authors.forename: Brendan
authors.initials: B
authors.lastname: Flannery
authors.forename: Scott F
authors.initials: SF
authors.lastname: Dowell
authors.forename: Salim
authors.initials: S
authors.lastname: Abdulla
authors.forename: S Patrick
authors.initials: SP
authors.lastname: Kachur
mesh_terms: D002648:Child; D002662:Child Health Services / Q000458:organization & administration*; D002675:Child, Preschool; D019468:Disease Management; D019983:Guideline Adherence; D017408:Guidelines as Topic; D006282:Health Personnel; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007407:Interviews as Topic; D011446:Prospective Studies; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D015996:Survival Rate; D013636:Tanzania / Q000453:epidemiology