Figure 1. Drug Distributors counting breathing rate on a child with pneumonia

Community health worker and caretaker recognition of pneumonia in children

Conclusions and policy implicationsCommunity health workers (CHWs), in Uganda ”drug distributors” or DDs, could successfully assess rapid breathing in children with pneumonia. Also caretakers were aware of ARI symptoms but linked them to fever and malaria treatment. To avoid over-treatment and failure-to-treat, highly focused training and context specific education messages are required. A standard set of both qualitative and quantitative methods are proposed as a toolkit. With such a standardised toolkit, the full-scale feasibility of integrated home and community management of both malaria and pneumonia should be tested.

Introduction Acute respiratory infections (ARI) are leading killers of children worldwide. Case management of ARI using CHWs has halved ARI mortality in children in Asia. WHO and UNICEF recommend integrating pneumonia care with Home Management of Malaria. However, in sub-Saharan Africa, performance of CHWs to assess rapid breathing has rarely been demonstrated.

Study objectivesTo assess antimalarial drug distributors (DDs) ability to assess rapid breathing in children under-five and to explore caretaker recognition and interpretation of pneumonia symptoms in western Uganda.

Karin Källander1, Göran Tomson1, Xavier Nsabagasani2, Jesca Nsungwa Sabiiti1,3,4, George Pariyo3 and Stefan Peterson1,3

1) Division of International Health (IHCAR) 2) Uganda Program for Human and 3) Institute of Public Health 4) Child Health Division Karolinska Institutet Holistic Development (UPHOLD) Makerere University Ministry of Health

Stockholm, Sweden Kampala Uganda Kampala Uganda Kampala, Ugandakarin.kallander@ki.se

MethodsQuantitative and qualitative methods were used. Ninety-six DDs were trained in recognition of pneumonia symptoms and their skills evaluated on in-patient children in the paediatric ward. Respiratory illness concepts and actions were obtained from a triangulation of 4 focus group discussions using video probing and feedback interviews with 2 key informants.

ResultsOf all CHW assessments 71% of were within ±5 breaths/minute from gold standard. Sensitivity of CHW classification was 87% and specificity 84%. Many local terms existed for respiratory illness, such as ‘Quick breathing’ and ‘Groaning breathing’. There was consistency in the interpretation of severity, cause and treatment of ARI - most being related to fever and treated with antimalarials.

Figure 2. Schematic presentation of DDs’ ability to classify children according to breathing rate.

All observationsn=576 (100 %)

Correctly classified compared to gold standardn=445 (79%)

Wrongly classified compared to gold standardn=119 (21%)

12 missing values

0%

10%

20%

30%

40%

50%

0% 20% 40% 60% 80% 100%

Failure-to-treat Over treatment

Percent of DD assessmentsPrevalence of pneumonia

Figure 3. The relationship between pneumonia prevalence and projected over treatment and failure to treat. Lines indicate the range resulting from sensitivity analysis for values of sensitivity (76-81 %)* and specificity (60-89%)*.

Table 1. Biomedical illness symptoms and ARI illness concepts among mothers in Western Uganda

Biomedical symptom Respiratory illness concept

  EkihahayiroQuick

breathing

ErihihiraShivering breathing

EkihumiraHeavy attack

ErihumayiraUnorganised

breathing

EkyikenyeroGroaning breathing

AkafundiNarrow space

ObukoniAbrupt attack

EkikubaChest

Hot body √ √ √   √      

Cough   (√) √ √ √ √   √

Fast breathing √ √   √ √   √  

Difficult breathing √   √ √ √ √ √  

Stridor           √    

Grunting         √   √  

Chest indrawing         √      

* Data deduced from Kolstad et al. (1997) Bull WHO, 75 Suppl 1:77-85 & Weber et al. (1997) Bull WHO, 75 Suppl 1:25-32