Students' Feedback Concerning the IMNCI Strategy.

Sir, 
 
The government of Gujarat (GOG) has implemented an Integrated Management of Neonatal and Childhood Illness (IMNCI) Strategy under Reproductive and Child Health (RCH) II. A step was taken, perhaps for the first time in India, to sensitize undergraduate (UG) students during their third M.B.B.S. (III/I batch/7th clinical term) by conducting a short training daily during their morning posting to preventive and social medicine for 3 hours over 10 days. Modules and physician chart books were provided to each UG free of cost by the GOG. 
 
In the Department of Community Medicine, Government Medical College, Surat Department of Pediatrics, pre-service IMNCI training for 127 students from batch 78 was conducted jointly in 2007. A self-administered questionnaire containing closed and a few open-ended questions was used to obtain feedback. Although it started with students, it was declared that this training will be a part of the internal assessment. 
 
Out of 127 students, 115 (90.5%) were present when evaluation forms were completed. All of the 115 students attended the training. A total of 91 (79.1%) students attended for all 10 days. Thirteen students (11.3%) were absent for 1 day and the remaining 11 students (9.6%) were absent for 2 days. None of the students were absent for 3 or more days. A total of 60 students (52.2%) found the training to be good; the remaining 55 students (47.8%) thought it was excellent. 
 
Students found the training oriented them towards clinical diagnosis as well as the management of pediatric illnesses. They felt that such training is needed by everyone as it teaches home-based care and is an easy way to reduce morbidity and mortality among children. It provided primary knowledge about child health as well as enhanced their ability to identify serious patients and provide emergency treatment and referral. They valued ward visits and algorithms to classify and manage the pediatric patient. 
 
Training methods were interactive and such practical approaches kept the students attentive. The method of teaching and training and the contents were found by the students to be logical and sequential. Contents were very clear and the method of delivery was lucid. IMNCI training involved mother or parents in treatment, which was beneficial for disease management. A total of 53 students (46.1%) found the training appealing as it used audio-visual aids for demonstration. Fourteen students (12.2%) found the training remarkable because it used disease classification. A majority (72.2%) of the students felt that it improved both their knowledge and skill regarding pediatric practice while 25 of the students (21.7%) thought it improved only their knowledge. The remaining 7 students (6.1%) felt it helped improve only their skill. 
 
A large number of students appreciated all components of the training. They suggested that this training should be given to all categories of health workers throughout India. Two studies that assessed the performance of health workers who had been trained in the full case management process(1,2) showed substantial success in their communication with mothers and in teaching them how to administer treatments at home. One student felt that it was oversimplification for medical students. IMNCI training should be made complex and the time duration should also be increased. Additional visits to wards should be planned and real cases should be given for assessment instead of hypothetical situations. 
 
When asked about the differences between conventional teaching and IMNCI training, students expressed that this is an excellent form of integrated teaching. A different modality of presentations is not seen during the usual teaching of pediatrics and preventive medicine. Active interest was created during this training, which reinforced their existing knowledge. 
 
Most of the opinions from students suggest that it was useful to them but will be more important and meaningful for health workers. 
 
The methodology was impressive and the whole program can increase the confidence of undergraduates in managing common pediatric morbidity and promoting positive behavioral changes. 
 
It will be premature to generalize the observations as it has just been started in Gujarat but students' perceptions and opinions can be of great help in organizing future IMNCI trainings.


Students' Feedback Concerning the IMNCI Strategy
Sir, The government of Gujarat (GOG) has implemented an Integrated Management of Neonatal and Childhood Illness (IMNCI) Strategy under Reproductive and Child Health (RCH) II. A step was taken, perhaps for the Þ rst time in India, to sensitize undergraduate (UG) students during their third M.B.B.S. (III/I batch/7th clinical term) by conducting a short training daily during their morning posting to preventive and social medicine for 3 hours over 10 days. Modules and physician chart books were provided to each UG free of cost by the GOG.
In the Department of Community Medicine, Government Medical College, Surat Department of Pediatrics, pre-service IMNCI training for 127 students from batch 78 was conducted jointly in 2007. A self-administered questionnaire containing closed and a few open-ended questions was used to obtain feedback. Although it started with students, it was declared that this training will be a part of the internal assessment.
Out of 127 students, 115 (90.5%) were present when evaluation forms were completed. All of the 115 students attended the training. A total of 91 (79.1%) students attended for all 10 days. Thirteen students (11.3%) were absent for 1 day and the remaining 11 students (9.6%) were absent for 2 days. None of the students were absent for 3 or more days. A total of 60 students (52.2%) found the training to be good; the remaining 55 students (47.8%) thought it was excellent.
Students found the training oriented them towards clinical diagnosis as well as the management of pediatric illnesses. They felt that such training is needed by everyone as it teaches home-based care and is an easy way to reduce morbidity and mortality among children.
It provided primary knowledge about child health as well as enhanced their ability to identify serious patients and provide emergency treatment and referral. They valued ward visits and algorithms to classify and manage the pediatric patient.
Training methods were interactive and such practical approaches kept the students attentive. The method of teaching and training and the contents were found by the students to be logical and sequential. Contents were very clear and the method of delivery was lucid. IMNCI training involved mother or parents in treatment, which was beneÞ cial for disease management. A total of 53 students (46.1%) found the training appealing as it used audio-visual aids for demonstration. Fourteen students (12.2%) found the training remarkable because it used disease classiÞ cation. A majority (72.2%) of the students felt that it improved both their knowledge and skill regarding pediatric practice while 25 of the students (21.7%) thought it improved only their knowledge. The remaining 7 students (6.1%) felt it helped improve only their skill.
A large number of students appreciated all components of the training. They suggested that this training should be given to all categories of health workers throughout India. Two studies that assessed the performance of health workers who had been trained in the full case management process (1,2) showed substantial success in their communication with mothers and in teaching them how to administer treatments at home. One student felt that it was oversimpliÞ cation for medical students. IMNCI training should be made complex and the time duration should also be increased. Additional visits to wards should be planned and real cases should be given

Challenges in Organizing Trauma Care Systems in India
Sir, Injury and trauma, often used interchangeably, represent a major health problem worldwide. Everyday around the world almost 16,000 people die from various injuries. Injuries represent 12% of the global burden of disease. (1) Road trafÞ c injuries are a major cause of mortality: 22.8% in the overall burden of death related to injuries. (2) It is startling to note that the lower and middle income group countries (which include India) contribute about 90% of the global burden of injury mortality, thus highlighting the disparities in outcome of trauma between the high, middle, and lower income nations. Injuries affect the productive youth of the country. In addition to excess mortality, there is a tremendous burden of disability from extremity, head, and spinal injuries in developing nations. The more tragic fact is that injury is the third most important cause of mortality and the main cause of death among 1 to 40-year-olds. Therefore, trauma effects the productive youth of the country, which is otherwise healthy and free from chronic disease. Road traffic injuries represent only a fraction of the trauma spectrum. In India, most of the available literature regarding trauma epidemiology is pertaining to road trafÞ c injuries (3) and there are hardly any studies done on the other causes of for assessment instead of hypothetical situations.
When asked about the differences between conventional teaching and IMNCI training, students expressed that this is an excellent form of integrated teaching. A different modality of presentations is not seen during the usual teaching of pediatrics and preventive medicine. Active interest was created during this training, which reinforced their existing knowledge.
Most of the opinions from students suggest that it was useful to them but will be more important and meaningful for health workers.
The methodology was impressive and the whole program can increase the conÞ dence of undergraduates in managing common pediatric morbidity and promoting positive behavioral changes.
It will be premature to generalize the observations as it has just been started in Gujarat but students' perceptions and opinions can be of great help in organizing future IMNCI trainings.
trauma. Trauma is caused by a wide variety of risks e.g., fall (common in pediatric patients), agricultural-related injuries, Þ rearm injuries, poisoning, burns, drowning, intentional self harm (suicides), assault, falling objects, natural-and man-made disasters.
The improved survival and functional outcome among injured patients in developed countries can be partly attributed to high-cost equipment and technology. Much of this high-end technology is unaffordable and unavailable to victims from developing nations. However, much improvement in the outcome of trauma patients has come from improvements in the organization of trauma care services in the form of developing trauma systems in given geographical areas. The improvement and organization of trauma services or trauma systems is a cost effective way of improving patient outcome and is achievable in almost all settings. (4,5) Proper organization of these systems reduces the time between injury and the deÞ nitive treatment thereby reducing morbidity and mortality. In India, such a trauma system is almost nonexistent and even if present in some urban areas, lacks the cohesive effort required. (6)