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Rawat A, Ameha A, Karlström J, Taddesse L, Negeri EL, Detjen A, Gandrup-Marino K, Mataruse N, Källander K, Tariku A. Health System Considerations for Community-Based Implementation of Automated Respiratory Counters to Identify Childhood Pneumonia in 5 Regions of Ethiopia: A Qualitative Study. Int J Health Policy Manag 2023; 12:7385. [PMID: 38618793 PMCID: PMC10699823 DOI: 10.34172/ijhpm.2023.7385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/30/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND In Ethiopia, childhood pneumonia is diagnosed in primary healthcare settings by measuring respiratory rate (RR) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. Our aim was to identify health system-level lessons from implementing two automated RR counters, Children's Automated Respiration Monitor (ChARM) by Phillips® and Rad-G by Masimo®, to provide considerations for integrating such devices into child health programmes and health systems. This study was part of an initiative called the Acute Respiratory Infection Diagnostic Aids (ARIDA). METHODS Key informant interviews (KIIs) were conducted with 57 participants (health workers in communities and facilities, trainers of health workers, district management, and key decision-makers) in five regions of Ethiopia. Data were analyzed in ATLAS.ti using thematic content analysis and themes were categorized using the Tanahashi bottleneck analysis. RESULTS All participants recommended scaling up the ARIDA initiative nationally as part of Integrated Management of Newborn and Childhood Illness (IMNCI) in primary healthcare. Health workers perceived the devices as: time saving, acceptable by parents and children, and facilitating diagnosis and referrals. Health workers perceived an increased demand for services and reduced numbers of sick children not seeking care. Participants recommended increasing the number of devices distributed and health workers trained. Strengthening drug supply chains, improving oxygen gas availability, and strengthening referral networks would maximize perceived benefits. While training improved knowledge, more supportive supervision, integration with current guidelines and more guidance related to community engagement was recommended. CONCLUSION Automatic RR counters for the decentralized diagnosis of childhood pneumonia could have positive impact on improving the quality of diagnosis and management of pneumonia in children. However, the study has shown that a health system approach is required to ensure all steps along the pneumonia pathway are adequate, including drug and oxygen supply, community engagement, health worker training and support, and referral pathways.
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Affiliation(s)
- Angeli Rawat
- UNICEF Supply Division Innovation Unit, Copenhagen, Denmark
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Agazi Ameha
- UNICEF Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Jonas Karlström
- UNICEF Supply Division Innovation Unit, Copenhagen, Denmark
- Global Programmes and Research, SingHealth Duke-NUS Global Health Institute, Duke-NUS, Singapore, Singapore
| | - Lisanu Taddesse
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | | | - Anne Detjen
- Child and Community Health Unit, Health Programme Group, UNICEF, New York City, NY, USA
| | | | | | - Karin Källander
- Digital Health and Health Information Systems Unit, Health Programme Group, UNICEF, New York City, NY, USA
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Abraham Tariku
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
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Khan SR, Wang X, Jiang T, Ju W, Radacsi N, Kadir MA, Rabbani KSE, Cunningham S, Mitra S. Multi-Modal Portable Respiratory Rate Monitoring Device for Childhood Pneumonia Detection. MICROMACHINES 2023; 14:708. [PMID: 37420941 DOI: 10.3390/mi14040708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/26/2023] [Accepted: 03/21/2023] [Indexed: 07/09/2023]
Abstract
Accurate assessment of Respiratory Rate (RR) is the most important mechanism in detecting pneumonia in low-resource settings. Pneumonia is a disease with one of the highest mortality rates among young children under five. However, the diagnosis of pneumonia for infants remains challenging, especially in low- and middle-income countries (LMIC). In such situations, RR is most often measured manually with visual inspection. Accurate RR measurement requires the child to remain calm without any stress for a few minutes. The difficulty in achieving this with a sick child in a clinical environment can result in errors and misdiagnosis, even more so when the child is crying and non-cooperating around unfamiliar adults. Therefore, we propose an automated novel RR monitoring device built with textile glove and dry electrodes which can make use of the relaxed posture when the child is resting on the carer's lap. This portable system is non-invasive and made with affordable instrumentation integrated on customized textile glove. The glove has multi-modal automated RR detection mechanism that simultaneously uses bio-impedance and accelerometer data. This novel textile glove with dry electrodes can easily be worn by a parent/carer and is washable. The real-time display on a mobile app shows the raw data and the RR value, allowing a healthcare professional to monitor the results from afar. The prototype device has been tested on 10 volunteers with age variation of 3 years to 33 years, including male and female. The maximum variation of measured RR with the proposed system is ±2 compared to the traditional manual counting method. It does not create any discomfort for either the child or the carer and can be used up to 60 to 70 sessions/day before recharging.
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Affiliation(s)
- Sadeque Reza Khan
- School of Engineering and Physical Sciences, Institute of Sensors, Signals and Systems, Heriot-Watt University, Edinburgh EH14 4AS, UK
| | - Xiaohan Wang
- School of Engineering, Institute of Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Tiantao Jiang
- School of Engineering, Institute of Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Wei Ju
- School of Engineering, Institute of Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Norbert Radacsi
- School of Engineering, Institute for Materials and Processes, The University of Edinburgh, Robert Stevenson Road, Edinburgh EH9 3FB, UK
| | - Muhammad Abdul Kadir
- Department of Biomedical Physics and Technology, University of Dhaka, Dhaka 1000, Bangladesh
| | | | - Steve Cunningham
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Srinjoy Mitra
- School of Engineering, Institute of Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh EH9 3FF, UK
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Khan AM, Ahmed S, Chowdhury NH, Islam MS, McCollum ED, King C, Shi T, Nahar K, Simpson R, Ahmed A, Rahman MM, Baqui AH, Cunningham S, Campbell H. Developing a video expert panel as a reference standard to evaluate respiratory rate counting in paediatric pneumonia diagnosis: protocol for a cross-sectional study. BMJ Open 2022; 12:e067389. [PMID: 36379660 PMCID: PMC9668034 DOI: 10.1136/bmjopen-2022-067389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Manual counting of respiratory rate (RR) in children is challenging for health workers and can result in misdiagnosis of pneumonia. Some novel RR counting devices automate the counting of RR and classification of fast breathing. The absence of an appropriate reference standard to evaluate the performance of these devices is a challenge. If good quality videos could be captured, with RR interpretation from these videos systematically conducted by an expert panel, it could act as a reference standard. This study is designed to develop a video expert panel (VEP) as a reference standard to evaluate RR counting for identifying pneumonia in children. METHODS AND ANALYSIS Using a cross-sectional design, we will enrol children aged 0-59 months presenting with suspected pneumonia at different levels of health facilities in Dhaka and Sylhet, Bangladesh. We will videorecord a physician/health worker counting RR manually and also using an automated RR counter (Children's Automated Respiration Monitor) from each child. We will establish a standard operating procedure for capturing quality videos, make a set of reference videos, and train and standardise the VEP members using the reference videos. After that, we will assess the performance of the VEP as a reference standard to evaluate RR counting. We will calculate the mean difference and proportions of agreement within±2 breaths per minute and create Bland-Altman plots with limits of agreement between VEP members. ETHICS AND DISSEMINATION The study protocol was approved by the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (registration number: 39315022021) and Edinburgh Medical School Research Ethics Committee (EMREC), Edinburgh, UK (REC Reference: 21-EMREC-040). Dissemination of the study findings will be through conference presentations and publications in peer-reviewed scientific journals.
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Affiliation(s)
- Ahad Mahmud Khan
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- Projahnmo Research Foundation, Dhaka, Bangladesh
| | - Salahuddin Ahmed
- Usher Institute, The University of Edinburgh, Edinburgh, UK
- Projahnmo Research Foundation, Dhaka, Bangladesh
| | | | | | - Eric D McCollum
- Department of Paediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Ting Shi
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Kamrun Nahar
- Department of Paediatrics, Shaheed Suhrawardi Medical College Hospital, Dhaka, Bangladesh
| | | | - Ayaz Ahmed
- Royal Hospital for Children, Glasgow, UK
| | - Md Mozibur Rahman
- Department of Neonatology, Institute of Child and Mother Health, Dhaka, Bangladesh
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Steve Cunningham
- Department of Paediatric Respiratory Medicine, The University of Edinburgh Centre for Inflammation Research, Edinburgh, UK
| | - Harry Campbell
- Usher Institute, The University of Edinburgh, Edinburgh, UK
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Field Experiences with Handheld Diagnostic Devices to Triage Children under Five Presenting with Severe Febrile Illness in a District Hospital in DR Congo. Diagnostics (Basel) 2022; 12:diagnostics12030746. [PMID: 35328299 PMCID: PMC8947034 DOI: 10.3390/diagnostics12030746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/10/2022] Open
Abstract
As part of a field study (NCT04473768) in children presenting with severe febrile illness to Kisantu hospital (DR Congo), we retrospectively compiled user experiences (not performance) with handheld diagnostic devices assisting triage: tympanic thermometer, pulse oximeter (measuring heart rate, respiratory rate and oxygen saturation), hemoglobinometer and glucometer. Guidance documents for product selection were generic and scattered. Stock rupture, market withdrawal and unaffordable prices interfered with procurement. Challenges at implementation included environmental temperature, capillary blood sampling (antisepsis, order of multiple tests, filling microcuvettes and glucose strips), calibration (environmental temperature, cold chain) and liability-oriented communication with a manufacturer. Instructions for use were readable and contained symbol keys; two devices had printed French-language instructions. Shortcomings were poor integration of figures with text and distinct procedures for the oximeter and its sensor. Usability interview revealed appreciations for quick results, visibility of the display and memory function (three devices) but also problems of capillary blood sample transfer, cleaning, too long of a time-to-results (respiratory rate) and size, fitting and disposal of thermometer probes. Pictorial error messages were preferred over alphanumeric error codes but interpretation of symbols was poor. Alarm sounds of the oximeter caused unrest in children and caretakers perceived the device as associated with poor prognosis.
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Tack B, Vita D, Mbaki TN, Lunguya O, Toelen J, Jacobs J. Performance of Automated Point-of-Care Respiratory Rate Counting versus Manual Counting in Children under Five Admitted with Severe Febrile Illness to Kisantu Hospital, DR Congo. Diagnostics (Basel) 2021; 11:2078. [PMID: 34829427 PMCID: PMC8623579 DOI: 10.3390/diagnostics11112078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
To improve the early recognition of danger signs in children with severe febrile illness in low resource settings, WHO promotes automated respiratory rate (RR) counting, but its performance is unknown in this population. Therefore, we prospectively evaluated the field performance of automated point-of-care plethysmography-based RR counting in hospitalized children with severe febrile illness (<5 years) in DR Congo. A trained research nurse simultaneously counted the RR manually (comparative method) and automatically with the Masimo Rad G pulse oximeter. Valid paired RR measurements were obtained in 202 (83.1%) children, among whom 43.1% (87/202) had fast breathing according to WHO criteria based on manual counting. Automated counting frequently underestimated the RR (median difference of -1 breath/minute; p2.5-p97.5 limits of agreement: -34-6), particularly at higher RR. This resulted in a failure to detect fast breathing in 24.1% (21/87) of fast breathing children (positive percent agreement: 75.9%), which was not explained by clinical characteristics (p > 0.05). Children without fast breathing were mostly correctly classified (negative percent agreement: 98.3%). In conclusion, in the present setting the automated RR counter performed insufficiently to facilitate the early recognition of danger signs in children with severe febrile illness, given wide limits of agreement and a too low positive percent agreement.
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Affiliation(s)
- Bieke Tack
- Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium;
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Daniel Vita
- Hôpital Général de Référence Saint Luc de Kisantu, Kisantu, Democratic Republic of the Congo; (D.V.); (T.N.M.)
| | - Thomas Nsema Mbaki
- Hôpital Général de Référence Saint Luc de Kisantu, Kisantu, Democratic Republic of the Congo; (D.V.); (T.N.M.)
| | - Octavie Lunguya
- Department of Microbiology, Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of the Congo;
- Department of Medical Biology, University Teaching Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jaan Toelen
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium;
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
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Ward C, Baker K, Smith H, Maurel A, Getachew D, Habte T, McWhorter C, LaBarre P, Karlstrom J, Black J, Bassat Q, Ameha A, Tariku A, Petzold M, Källander K. Usability and acceptability of an automated respiratory rate counter to assess children for symptoms of pneumonia: A cross-sectional study in Ethiopia. Acta Paediatr 2020; 109:1196-1206. [PMID: 31638714 PMCID: PMC7317341 DOI: 10.1111/apa.15074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/14/2019] [Accepted: 10/21/2019] [Indexed: 11/27/2022]
Abstract
AIM Manually counting respiratory rate (RR) is commonly practiced by community health workers to detect fast breathing, an important sign of childhood pneumonia. Correctly counting and classifying breaths manually is challenging, often leading to inappropriate treatment. This study aimed to determine the usability of a new automated RR counter (ChARM) by health extension workers (HEWs), and its acceptability to HEWs, first-level health facility workers (FLHFWs) and caregivers in Ethiopia. METHODS A cross-sectional study was conducted in one region of Ethiopia between May and August 2018. A total of 131 HEWs were directly observed conducting 262 sick child consultations after training and 337 after 2 months. Usability was measured as adherence to the WHO requirements to assess fast breathing and device manufacturer instructions for use (IFU). Acceptability was measured through semi-structured interviews. RESULTS After 2 months, HEWs were shown to adhere to the requirements in 74.6% consultations; an increase of 18.6% after training (P < .001). ChARM is acceptable to users and caregivers, with HEWs suggesting that ChARM increased client flow and stating a willingness to use ChARM in future. CONCLUSION Further research on the performance, cost-effectiveness and implementation of this device is warranted to inform policy decisions in countries with a high childhood pneumonia burden.
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Affiliation(s)
| | - Kevin Baker
- Malaria ConsortiumLondonUK
- Department of Public Health SciencesKarolinska InstitutetSolnaSweden
| | | | | | | | | | | | | | | | - Jim Black
- FREO2 Foundation LtdMelbourneAustralia
| | - Quique Bassat
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saúde de Manhiça (CISM)MaputoMozambique
- ICREABarcelonaSpain
- Pediatric Infectious Diseases UnitPediatrics DepartmentHospital Sant Joan de Déu (University of Barcelona)BarcelonaSpain
| | | | | | - Max Petzold
- School of Public Health and Community MedicineInstitute of MedicineUniversity of GothenburgGothenburgSweden
| | - Karin Källander
- Malaria ConsortiumLondonUK
- Department of Public Health SciencesKarolinska InstitutetSolnaSweden
- Programme DivisionUNICEFNew YorkNYUSA
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Källander K, Ward C, Smith H, Bhattarai R, KC A, Timsina D, Lamichhane B, Maurel A, Ram Shrestha P, Baral S, McWhorter C, LaBarre P, de Cola MA, Baker K. Usability and acceptability of an automated respiratory rate counter to assess childhood pneumonia in Nepal. Acta Paediatr 2020; 109:1207-1220. [PMID: 31762072 PMCID: PMC7318335 DOI: 10.1111/apa.15108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 01/03/2023]
Abstract
AIM Pneumonia is the leading cause of child death after the neonatal period, resulting from late care seeking and inappropriate treatment. Diagnosis involves counting respiratory rate (RR); however, RR counting remains challenging for health workers and miscounting, and misclassification of RR is common. We evaluated the usability of a new automated RR counter, the Philips Children's Respiratory Monitor (ChARM), to Female Community Health Volunteers (FCHVs), and its acceptability to FCHVs and caregivers in Nepal. METHODS A cross-sectional study was conducted in Jumla district, Nepal. About 133 FCHVs were observed between September and December 2018 when using ChARM during 517 sick child consultations, 264 after training and 253 after 2 months of routine use of ChARM. Acceptability of the ChARM was explored using semi-structured interviews. RESULTS FCHV adherence to guidelines after 2 months of using ChARM routinely was 52.8% (95% CI 46.6-58.9). The qualitative findings suggest that ChARM is acceptable to FCHVs and caregivers; however, capacity constraints such as older age and low literacy and impacted device usability were mentioned. CONCLUSION Further research on the performance, cost-effectiveness and implementation feasibility of this device is recommended, especially among low-literate CHWs.
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Affiliation(s)
- Karin Källander
- Malaria Consortium London UK
- Programme Division Health Section UNICEF New York NY USA
- Department of Public Health Sciences Karolinska Institutet Stockholm Sweden
| | | | | | | | - Ashish KC
- Health & Nutrition Section UNICEF Nepal Kathmandu Nepal
- Department of Women's and Children's Health International Maternal and Child Health (IMCH) Uppsala University Uppsala Sweden
| | | | - Bikash Lamichhane
- Department of Health Services Ministry of Health & Population Kathmandu Nepal
| | | | | | | | - Cindy McWhorter
- UNICEF Supply DivisionProduct Innovation CentreCopenhagen Denmark
| | - Paul LaBarre
- UNICEF Supply DivisionProduct Innovation CentreCopenhagen Denmark
| | | | - Kevin Baker
- Malaria Consortium London UK
- Department of Public Health Sciences Karolinska Institutet Stockholm Sweden
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