PNEUMONIA DIAGNOSTICS PROJECT Diagnos… · PNEUMONIA DIAGNOSTICS PROJECT “Pneumonia Diagnostics Project: A study to evaluate and identify improved tools for the measurement of

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PNEUMONIA DIAGNOSTICS PROJECT “Pneumonia Diagnostics Project: A study to evaluate and identify improved tools for the measurement of respiratory rate and oxygen saturation for the diagnosis of pneumonia

by community health workers and first level health facility workers”

RESEARCH STAGE 1 REPORT

Authors:

Dr. LENA MATATA, PROJECT MANAGER

SAM B.T OKELLO, RESEARCH OFFICER

Malaria Consortium

Submission date: December 2014

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Table of Contents

Table of Contents ................................................................................................................................................................ 2

Abbreviations ...................................................................................................................................................................... 3

Acknowledgements ............................................................................................................................................................ 4

Abstract ................................................................................................................................................................................ 4

Introduction ......................................................................................................................................................................... 5 Study background ............................................................................................................................................................................. 6 Study aims and objectives ............................................................................................................................................................... 7

Methods ............................................................................................................................................................................... 7 Study design ....................................................................................................................................................................................... 7 Study Site ............................................................................................................................................................................................ 8 Study population ............................................................................................................................................................................. 10 Data collection ................................................................................................................................................................................. 12 Data analysis .................................................................................................................................................................................... 14

Results ................................................................................................................................................................................ 14 Theme 1: CBDs Knowledge and Management of Pneumonia in the Local Health Situation ............................................ 14

Felt Need, Common Illnesses..................................................................................................................................................................... 14 CBDs Knowledge on Identifying Signs and Symptoms of Pneumonia ................................................................................... 15 CHWs Accessibility, Community Engagement in iCCM and Community Treatment Options ...................................... 17 Availability of Diagnostic Tools and Adequate Supply of Antibiotics .................................................................................... 19

Theme 2: Current Constraints in Pneumonia Care at the Community Level ....................................................................... 20 Forgotten iCCM Guidelines ...................................................................................................................................................................... 20 Constraints with Availability of Diagnostic Tools and Adequate Supply of Antibiotics ................................................. 21 Device Use Constraints .............................................................................................................................................................................. 22 Need for Refresher Training ................................................................................................................................................................... 23

Theme 3: Ideal Tool Characteristics for Pneumonia Diagnosis: ............................................................................................. 24 Responses on Ideal Tool Characteristics when considering, Device Usability .................................................................. 24 Ideal Tools Designs ..................................................................................................................................................................................... 25

Discussion ........................................................................................................................................................................... 27 Communication implications ........................................................................................................................................................ 27 Study limitations ............................................................................................................................................................................. 29 Conclusion ........................................................................................................................................................................................ 30

Appendices......................................................................................................................................................................... 30

Appendix 1: Stage 1 Research FGD Participants ......................................................................................................... 31

Appendix 2: FGD Information Sheet (English and Dinka Translation)..................................................................... 31

Appendix 3: Stage 1 Research FGD Participants Responses ..................................................................................... 36

Results ................................................................................................................................................................................ 36 Theme 1: CBDs Knowledge and Management of Pneumonia in the Local Health Situation ............................................ 36 Theme 2: Current Constraints in Pneumonia Care at the Community Level ....................................................................... 52 Constraints with availability of diagnostic tools and adequate supply of antibiotics ....................................................... 57 Theme 3: Ideal Tool Characteristics for Pneumonia Diagnosis: ............................................................................................. 66

Appendix 4: Preliminary Results Summary for Stage 1 Research ............................................................................ 72

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References ......................................................................................................................................................................... 76

Abbreviations

ARI Acute Respiratory Infections

BRAC Bangladesh Rural Advancement Committee

CBDs Community Based Distributers

CDDs Community Drug Distributers

CHDs County Health Departments

CHWs Community Health Workers

County Health Departments

FGD Focus Group Discussion

iCCM integrated Community Case Management

iNGOs international non-governmental organisations

IRC International Rescue Committee

MoH Ministry of Health

NBEG Northern Bahr El Ghazal

PHCC Primary Health Care Centre

PHCU Primary Health Care Unit

PSI Population Services International

SMoH State Ministry of Health

SS South Sudan

SSHHS South Sudan Household and Health Survey

UMR Under-five Mortality Rate

WHO World Health Organization

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Acknowledgements

The Pneumonia Diagnostics Project is funded by the Bill and Melinda Gates Foundation.

Thank you to the integrated Community Case Management (iCCM) Community Health Workers who are

referred to as Community Based Distributer’s (CBDs) and their supervisor’s in Aweil West and Aweil Centre,

Northern Bahr El Ghazal-South Sudan, iCCM Malaria Consortium team and the Ministry of Health - Republic of

South Sudan, State Ministry of Health, Northern Bahr El Ghazal and County, Payam officials in Aweil West and

Centre, Northern Bahr El Ghazal.

Abstract

Malaria Consortium conducted a formative research study amongst iCCM Community Health Workers. The

aim was to gain an understanding of their current experiences diagnosing the signs of pneumonia in children

and specifically relating their experiences in using diagnostics devices to capture their current constraints and

enablers in diagnosing pneumonia at the community level and suggestions on characteristics of a tool that

could improve the accuracy of pneumonia diagnosis and which will also be acceptable to the caretakers.

The study was conducted using Focus Group Discussions (FGDs) with 24 iCCM CBDs, who are referred to as

Community Based Distributer’s (CBDs) or Community Drug Distributers (CDDs) in Aweil West and Aweil Centre

counties in Northern Bahr El Ghazal, South Sudan. The data was collected by using both field notes and audio-

recorders; this data was used to write fair notes and transcribed into transcripts that were analysed using

NViVo software.

The iCCM CBDs (N=12 of 24) mentioned that pneumonia was the most common childhood disease in the

community, whereas malaria and diarrhoea was mentioned by 3 CBDs each. The FGD data found that a good

number of the CBDs are able to correctly identify the common signs and symptoms of pneumonia, but it was

also clear from the FGD that a number of the CBDs struggle with both the identification and management of

pneumonia using the iCCM guidelines and using the tools provided, the counting beads and ARI timer.

The iCCM CBDs mentioned that they experience challenges with the current pneumonia devices; for example

the devices are not long-lasting, are not easy to use and therefore they are not always confident in making

decisions on whether to treat a child with antibiotics for pneumonia.

The iCCM CBDs felt that it is possible to improve on the current pneumonia diagnostics devices, by having

devices that are less cumbersome to use, devices that are not easily damaged and when the devices are

powered by use of a battery, the battery ought to be long-lasting, they also preferred automated devices that

read and display the child’s breathing rate.

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Introduction

Pneumonia is the number one infectious killer of children under age 5 globally. In children under five years of

age, the disease accounts for 1 million deaths annually, representing 15% of all under-five annual worldwide

mortality (WHO 2014). Many deaths result from late care seeking and inappropriate treatment due to lack of

caregiver awareness of pneumonia symptoms and misdiagnosing symptoms as malaria (UNICEF/WHO 2006).

While caregivers may recognize rapid breathing in a coughing child, it does not always prompt care-seeking

actions, resulting in delays and development of more severe disease (Kallander, Tomson et al. 2006, Kallander,

Tomson et al. 2006, Kallander, Hildenwall et al. 2008). Children who are taken for treatment late are at risk of

developing severe pneumonia and the inability of health care workers to adequately recognize danger signs,

which indicate that the child needs urgent referral to a higher level of care, leads to the death of many

children (Bojalil, Kirkwood et al. 2007).

In South Sudan, Infant and under-five mortality rate (UMR) are very high; at 75 and 105 deaths per 1000 live

births, respectively (SSHHS 2010). Pneumonia is one of the major causes of infant and children under five,

morbidity and mortality in South Sudan. The other major causes of infant and under-five morbidity and

mortality are malaria, diarrheal diseases, and malnutrition, and they are also common co-infections in a child

with pneumonia (MoH-GOSS 2011).

On average children less than five years of age in South Sudan, get infected with an acute respiratory tract

infection once every 1-2 months (MoH-GOSS 2009), which is an equivalent of 6-12 attacks per child under 5

years of age in a year, the 2010 SSHHS showed that 19% of children under five had had symptoms of

suspected pneumonia in the last two weeks, which is a substantial increase from 14% seen in the same survey

conducted in 2006 (MoH-GOSS 2006, MoH-GOSS 2011). This frequency of pneumonia morbidity is significant

as children under 5 years of age make up 16% of the total population of South Sudan (MoH-GOSS 2011, SSNBS

2011).

The 2010 SSHHS found that 47.2 per cent of mothers’ in South Sudan, had knowledge on the key danger signs

of pneumonia which is an improvement from 24.5 per cent in the 2006 survey (MoH-GOSS 2006, MoH-GOSS

2011); the target for South Sudan is that 60 per cent of mothers by 2015 should have knowledge of the danger

signs of pneumonia. It was also found that 47 per cent of children with suspected pneumonia got care from an

appropriate health care provider and 33 per cent were treated with antibiotics (MoH-GOSS 2011), the Global

Action Plan for Prevention and Control of Pneumonia targets for these two indicators is 90 per cent (IVAC

2012).

The risk factors for childhood pneumonia in South Sudan are; weaning of children before completing 6 months

of exclusive breastfeeding, protein energy malnutrition, micronutrient deficiencies especially vitamin A and

zinc deficiencies, complication after malaria illness, incomplete vaccine coverage against common illnesses,

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children being exposed to cooking smoke as more than 99% of households were found to use solid fuel for

cooking (MoH-GOSS 2011), living in cold, highland areas and in over-crowded conditions (MoH-GOSS 2009).

One of the strategies by the SS MoH to combat high mortality rates in children under 5 years of age in South

Sudan is the community based child survival program, and this includes ‘integrated community case

management (iCCM) as outlined in the national guideline for “community based management of malaria,

pneumonia and diarrhoea” (MoH-GOSS 2009). The iCCM program in South Sudan has been implemented since

2005, with more than 9 000 CBDs in 30 of the 79 counties of South Sudan, with support to the MoH-SS from

international non-governmental organisations (iNGOs) including Malaria Consortium (Olivi , MoH-GOSS 2009,

DFID 2013, Malaria-Consortium 2013). The national guideline outlines the approach for the recruitment of

CBDs, who are volunteers, selected by the community, and are trained in the elements of the community

health package for malaria, diarrhoea and pneumonia.

The selection of the CBDs is done through a consultative process by village leaders, chiefs and members of the

community. Information from the iNGOs indicates that majority of CBD volunteers are females, for example at

the time of the FGDs, Malaria Consortium was working with 1 676 CBDs and of these 1 111 (66.3%) were

female. The following iNGOs also report that a higher number of the CBD volunteers they work with are

female; Population Services International (PSI), International Rescue Committee (IRC), Save the Children and

Bangladesh Rural Advancement Committee (BRAC), the CBD volunteers working with BRAC are all female

whereas IRC indicates that majority of their CBDs are mothers (MoH-GOSS 2009, Matata 2014). Majority of

the CBD volunteers are illiterate, therefore their training is practical using demonstrations and role plays,

(MoH-GOSS 2009). In a study assessing the use of counting beads amongst CHWs in South Sudan, Uganda and

Ghana, 100 per cent of the fifty nine CBD participants from South Sudan, and who were working with IRC and

Save the Children were illiterate. The low literacy rates have led to innovative training materials; Malaria

Consortium for instance, has developed pictorial learning job aids (Malaria-Consortium 2013).

Study background

As per the World Health Organization (WHO) guidelines for Integrated Management of Childhood Illnesses

(WHO 2013) and for Integrated Community Case Management (WHO/UNICEF 2012), diagnosis of pneumonia

at lower level health facilities and in the community is largely presumptive and based on increased respiratory

rate (RR) in children with cough or difficulty in breathing.

A number of counting aids have been developed to facilitate low literate CBDs to assess and classify symptoms

of pneumonia. CBDs are trained to assess, classify and treat children with pneumonia, malaria and diarrhoea

using the WHO protocol. The recommended timing device for assessment of fast breathing to classify

pneumonia is the ARI timer developed by UNICEF. During training of CBDs in South Sudan, Northeast Uganda

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and Ghana, any timing device, which required health workers to count breaths, was deemed inappropriate

(Noordam, Barbera Lainez et al. 2014). As a result, a counting device in the form of beads was developed.

More recently, and partly as a response to the scale-up of large ICCM projects in Sub-Saharan Africa and South

Asia, new pneumonia diagnostic support aids have been developed by industry, academia and other partners

to improve the accuracy and effectiveness of diagnosing pneumonia in resource-poor contexts (UNICEF 2013).

Wider use of diagnostic support aids for pneumonia and user-friendly pulse oximetry (POx) devices are

expected to contribute to improved, more accurate diagnosis and classification of pneumonia, thereby

yielding improved treatment, reduced margin of error and better sensitivity and specificity.

A priority need is therefore the clinical evaluation of these new technologies compared to the UNICEF ARI

timer, including an assessment of the acceptability and usability of these new approaches from the

perspective of the CHW, clinical staff working in first level health facilities, as well as the caregiver of the child.

Malaria Consortium is implementing an eighteen-month grant to carry out operational research on

pneumonia diagnostic tools in Cambodia, Ethiopia, Uganda and South Sudan.

Study aims and objectives

Malaria Consortium conducted a formative research study amongst iCCM Community Health Workers. The

aim was to gain an understanding of their current experiences diagnosing the signs of pneumonia in children

and specifically relating their experiences in using diagnostics devices to capture their current constraints and

enablers in diagnosing pneumonia at the community level and suggestions on characteristics of a tool that

could improve the accuracy of pneumonia diagnosis and which will also be acceptable to the caretakers.

The study objectives were based on three themes to identify the current constraints and enablers amongst

iCCM CBDs in regards to:

Community Health Worker’s knowledge and management of pneumonia in the local health situation

Community Health Worker’s experiences in detecting the signs and symptoms of pneumonia and

managing children with pneumonia at the community level

Community Health Worker’s views on ideal tool characteristics for pneumonia diagnosis

Methods

Study design

This study is the stage one of six stages for this project. Stage one data was collected in May and June 2014,

through formative research method, through three Focus Group Discussions, with 8 iCCM, Community Health

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Workers at each FGD. The CBDs are referred to as Community Drug Distributers (CDDs) or Community Based

Distributer’s (CBDs), working with the Malaria Consortium, iCCM program in Aweil West and Aweil Centre

Counties in Northern Bahr El Ghazal state (NBEG), South Sudan (see Map 1).

Map 1. Map of Northern Bahr El Ghazal Counties, South Sudan

Study Site

Northern Bahr el Ghazal is one of the 10 states in South Sudan. It is located North-West of the country and

covers a total area of 30 543 square km (SSNBS 2011).

The total population of NBEG is 721 000 and it is the most rural state in South Sudan, 92% of the NBEG

population lives in rural areas (SSNBS 2011). This state has 5 counties (see Map 1). Malaria Consortium is

working with the South Sudan Ministry of Health (SS MOH) in iCCM in 2 of the 5 counties, Aweil Centre and

Aweil West. The SS MOH organizational structure divides Counties into smaller units called Payams, and the

Payams into smaller units termed as Bomas (see Figure 1 below).

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Figure 1. The Organizational and Management Structure of South Sudan Ministry of Health (SSMOH 2012)

The South Sudan health system is decentralized and based on four levels: the community level Primary Health

Care Unit (PHCU); first referral Primary Health Care Centre (PHCC); second referral County and State Hospitals

and 3 National Referral Hospitals. Service delivery is the responsibility of State Ministries of Health (SMoH) and

the County Health Departments (CHDs) while the national Ministry of Health (MoH) provides leadership

through setting policy and guidelines, resource mobilization, and health sector partnerships coordination.

South Sudan has prioritized ‘community health systems strengthening’ aimed at improving community health

services, which mainly target vulnerable populations with limited access to the formal health system, mainly

due to log distance from health facilities, as only 44% of the population is estimated to be living within a five

kilometre radius of a health facility (SSMoH-NGOHF 2011, MoH-GOSS 2012). CBDs who deliver iCCM are linked

to the formal health system through training, support supervision and replenishment of medicines/supplies

(MoH-GOSS 2009).

In South Sudan, Malaria Consortium currently implements ICCM in Aweil Centre and West counties in

Northern Barh El Ghazal state (see Map 1). At the time of the FGDs, 1,676 CBDs were working with the

programme (of whom 66.7% were female). The1 676 CBDs had all been trained in the Home Management of

Malaria program, with 955 trained for six days on the full ICCM package, as of November 2014 all the CBDs

were trained in the full iCCM package. It is recommended that the community should select CBD volunteers

who are adults of good standing in the community and should be above 18 years of age. Malaria Consortium is

currently collecting demographic data including age information on the CBDs.

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The majority of CBDs have extremely low literacy and numeracy as they have not attended formal education,

hence within the program, the training on pneumonia diagnosis uses, pictorial job aids and two pneumonia

diagnostic devices for facilitating counting of respiratory rate in children with cough, namely: ARI timers and

counting beads for infants and toddlers. The beads are color-coded and in different sizes to separate the two

age groups.

Picture 1: Female CBD speaking to a mother in the community

Study population

A stratified sampling approach was followed considering Sex, County and Payam of work to select 24 CBDs,

engaged in iCCM work with SS MOH and Malaria Consortium in Aweil Centre and Aweil West counties. The

sampling was done from an existing Malaria Consortium database listing a total of 1676 iCCM CBDs. The

sampling criteria would have ideally included information on age, education and length of work-experience for

the CBDs but this information was not available in our database.

The final list of 24 CBDs was affected by inadequate data on CBDs in existing data base, communication of FGD

invitation was hampered by lack of mobile phone signal in the study area and distances of CBDs, availability of

invited CHW, distance to FGD venue and this led to a sample of 14 males and 10 females (instead of the

expected sample of 8 males and 16 females). (See: Sampling Frame Diagram below).

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Sampling Frame Diagram: 24 iCCM Community Health Workers, who participated in FGD for Pneumonia Diagnostics, Stage 1

Research

Demographic characteristics of the 24 participants; 58% were male, the age range was 21-35 years (average

28 years), the range for length of experience as a CHW was 2-6 years (average 4 years) (see Appendix 1).

Replacement of participants occurred on the day of all 3 FGD sessions. In total 6 participants were replaced for

the following reasons: they could not be traced because they were residing in a difficult to access region of the

study area and lived in an area with no mobile phone network (N=3), received the invitation, but were residing

too far from the discussion venue (N=2), received the invitation but our data-base had not yet been updated

to indicate that this participant was no longer working in the ICCM program (N=1).

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Data collection

Ethical approval for the study was granted by, the Directorate of Policy, Planning, Budgeting and Research,

Ministry of Health-Republic of South Sudan on 23rd May 2014.

Four Research assistants were recruited from the local community and were trained over 3 days on the

research goal, research objectives, how to conduct focus group discussions and they were trained on

obtaining informed consent. The information and consent documents had been translated into Dinka language

(see Appendix 2). They reviewed both the English and Dinka documents and they participated in mock FGD

sessions. They were further trained in data management.

The research assistants participated in the pre-testing of the documents in one pilot with four CBDs (two male

and two female) and this gave an opportunity to improve on the FGD skills.

The research assistants were provided with the list of names of 24 CBDs who were to participate in the three

FGDs, and using their local knowledge and working with the Payam level administration, they were able to

organize the three central points for conducting the FGDs in the community and also send prior invitations to

the CBDs. (see picture 1 and 2, FGD session in the community).

The four research assistants assigned themselves responsibilities for the FGDs: moderator, note-taker

(recorder) and observer. The 3 FGDs were conducted in May and June 2014; each session was conducted with

8 CBDs, and lasted approximately 2 hours.

At each FGD, the moderator welcomed the participants and explained the purpose of the FGD. The note-taker

gave each participant two copies of the information sheet/consent form, which had the information written in

English and Dinka languages (see Appendix 2), the note-taker read and explained the information to the

participants, written informed consent was then obtained from each participant by them signing two copies of

the consent form; each of the participants was given a copy of the signed form. The investigator’s copies of

the signed consent forms are stored in a locked metallic cabinet in the Malaria Consortium office in Aweil

Centre town. The field, fair-notes and final transcripts were anonymized, code R was used for the researcher,

code I for interviewees (see Appendix 1).

The moderator then led the discussion in Dinka language using the FGD guide and the note-taker recorded the

notes, the notes collected at this stage were field notes, written either in Dinka or English depending on the

note-taker’s ability to write in that language. A third research assistant recorded observations during the FGD.

The FGD was audio-recorded using two audio-recorders.

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At the end of the FGD the investigator’s copy of the signed consent form, the FGD attendance list, and the

field notes were kept in a waterproof bag and carried back to the Malaria Consortium office in Aweil Centre

town. The field notes were photocopied, and the photocopied notes were stored separately from the original

notes. The audio-records were downloaded onto a computer and external hard-drive, the informed consent

documents, attendance sheets had participant identifiers and they were therefore stored separately.

The research assistants then used the field notes and audio recordings to translate and type the FGD into two

fair notes (one for the information obtained by note-taking and the second for information obtained by audio-

recording), the two fair notes were provided to the research officer and project manager who then proceeded

to transcribe the fair-notes into three transcripts, one each for the three FGDs.

Picture 2 FGD participants reading the research information sheets

Picture 3 FGD session in the community

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Data analysis

Preliminary thematic analysis using the fair-notes was done around the three main themes outlined in the

topic guide and summarized in a simplified table (see Appendix 3).

The next stage of the analysis involved a detailed review of the final verbatim transcripts and the development

of a global coding frame through discussions and consensus by the country teams, the coding framework

encompassed the themes that emerged from the FGDs in all four countries, a senior specialist led this process.

The senior specialist centrally uploaded the coding framework and transcripts from the three FGDs in each

country into Nvivo 10 software. The country teams proceeded to conduct the data analysis and coding of their

respective transcripts using Nvivo software, the Nvivo coding reports generated by the country teams were

reviewed by the senior specialist. In cases of discrepancies, the affected themes and sub-themes were

discussed and the data re-coded, new themes were added when necessary through a consensus process. This

approach ensured that the data analysis was standardized across the four countries.

Results

The full FGD responses are tabled in Appendix Three (page 34).

Theme 1: CBDs Knowledge and Management of Pneumonia in the Local Health Situation

Felt Need, Common Illnesses

18 of the 24 respondents gave their views on what they felt was the common childhood disease in the

community and 12 of the 24 responded that pneumonia was the most common childhood disease; malaria

and diarrhoea were each mentioned by three respondents.

The three diseases together with malnutrition have been identified by the South Sudan Household and Health

Surveys’ to be the leading causes of morbidity and mortality in children under five years in South Sudan, and

are amongst the priority diseases to improve child health indicators in South Sudan (MoH-GOSS 2006, MoH-

GOSS 2011, MoH-GOSS 2012).

Examples of the responses for the 18 respondents are as follows:

Pneumonia

SSP1F1R7 “Pneumonia is the most common in our area because mothers do not take good care of the children.

This is because, they don’t have knowledge of preventing pneumonia, like keeping their children in a warm

place not to get cough”.

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SSP2F2R4. “Yes, I think pneumonia is the most common disease that is killing children less than 5 years of age

because mothers do not know how to protect their children from pneumonia; it is the most dangerous disease

in our community”.

SSP3F3R7 [Smiling] “Pneumonia is the disease which affects children under 5 years old the most. This is

because mothers do not take good of their children by exposing them to cool weather and also by bathing

them at wrong hours for example at night, also they fail to cover them using blankets which encourages

pneumonia in this area”.

Malaria

SSP1F1R4 “Well, Malaria is the most common one in this area because of mosquito bites and also many people

lack mosquito nets and they come to me seeking for treatment”.

Diarrhoea

SSP3F3R2 “Diarrhoea this is because of poor sanitation in the areas where parents fail to practice good

sanitation at their homes”.

CBDs Knowledge on Identifying Signs and Symptoms of Pneumonia

The responses indicate that In general a number of CBDs are able to correctly and confidently identify and

examine a child for the common signs and symptoms of pneumonia, additionally a few CBDs were able to

demonstrate knowledge on examining a child with pneumonia for danger signs.

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This is a reflection that the iCCM program is able to train community volunteers who are largely illiterate, by

using simple algorithms and pictorial job aids in managing an important childhood disease at the community

level.

Examples of the responses of CBDs who demonstrated basic knowledge on identifying and examining a child

for the common signs and symptoms of pneumonia:

SSPF2R1: “Cough is a sign and symptom of pneumonia I have to use respiratory timer and respiratory beads to

examine whether the child has pneumonia or not and if it reads red that means the child has pneumonia I can

give treatment Amoxicillin depending on the child’s age”.

SSP2F2R2: “In that case, for me I have to observe or assess the child whether child has fast breathing and

cough or not, and if he or she has those signs and symptoms it means the child has pneumonia and he or she is

eligible to be treated using amoxicillin depending on the child’s age. However, before that I have to examine

the child using respiratory timer and respiratory beads”.

Example of the responses that aimed to describe CBDs knowledge on identification of danger signs in a child with pneumonia.

SSP2F2R6 “Chest in drawing is also a common sign and symptom for pneumonia in children less than 5 years of

age. A child with chest in drawing has a danger sign and such a child is given the first treatment and sent to the

nearest health facility for additional check up by nurse or clinical officers”.

The study also found that most CBDs demonstrated that they are able to correctly use the two diagnostic

devices, ARI timer and counting beads to count a child’s breathing rate, and make decisions to prescribe

antibiotic treatment for pneumonia:

Examples of the responses on device usability, correct use of ARI timer and counting beads include:

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SSP2F2R1: “For me, I have to welcome the caretaker to sit and I give him or her some drinking water, then he

or she will explain the child’s problem and if it is cough, I have to tell the mother to breastfeed the child

whether the child will cough or not before I decide. Cough is a sign and symptom of pneumonia I have to use

respiratory timer and respiratory beads to examine whether the child has pneumonia or not and if it reads red

that means the child has pneumonia I can give treatment Amoxicillin depending on the child’s age”.

SSP2F2R5. “Well, for me, they normally come to me to ask for treatment of pneumonia, and I have to tell the

caretaker to remove the child’s cloth then I begin to examine the child using respiratory timer while counting

beads before giving drugs for pneumonia”.

CHWs Accessibility, Community Engagement in iCCM and Community Treatment Options

The community in Aweil Centre and West, has two main treatment options for management of childhood

pneumonia; community management by CBDs due to their accessibility and the fact that the community is

aware they have been trained and have medicines, the community and community leaders have embraced

the iCCM program, and are involved in selecting the appropriate volunteers to be trained as CBDs. The CBDs

expressed that they take this responsibility seriously and are always available to serve the community, some

of the CBDs expressed that they also conduct home visits to follow-up on sick children. The alternative

treatment option for pneumonia is health facilities (PHCC, PHCU) and these are used by the community when

they are referred their by the CBDs for; management of danger signs, cases that are too difficult for the CBDs

to manage, age groups that are not treated by CBDs as per iCCM algorithm or when the CBD has run out of

medication.

Example of responses indicating CBDs, availability and positive attitude towards community management of

childhood pneumonia include:

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SSP2F2R3. “Yeah, I attend to all the children in the community because the community selected me to help

children less than 5 years of age. I was trained by ICCM team to give the support needed by my people so; I

have to serve all of them if there are enough drugs”.

SSP2F2R1: “Yes, I manage to carry out my entire task assigned to me by Malaria Consortium because, I have to

save my people and that is why I was chosen among the group in our village to help them”.

SSP1F1R4 “I go to their homes to check how the children slept in the night and to get more information about

the children’s health and if there is a problem I can be able to know from them”.

Responses indicating Community Awareness of the iCCM program, Community Involvement in the iCCM program and Confidence in the use of CBDs for community management of pneumonia include:

SSP1F1R3 “They come to us because we have been trained as CBDs and also because of the kind of services we

are giving them. Since they know we are working to help the community at large”.

SSP1F1R3 “Yeah I have been given the green light by the community and government to carry out my duties

and to help children under 5 years who are suffering from pneumonia”.

SSP2F2R7. [Smiling] the community is very happy about the services we give and that encourages people to

come for treatment, I normally do my part if the drugs are available.

Responses indicating Alternative Treatment option for the community (health facility) include:

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SSP3F3R1 “They come to me to get treatment because they know I have been trained and I have been given

drugs by Malaria Consortium, after my visit if I find that the child has not improved I have to refer to PHCC or

PHCU”.

SSP2F2R4. “I normally go to their homes after giving the treatment because sometimes our tools are not good

enough to show accurate results. The reason is that, the child may have a different sickness from pneumonia or

I counted the respiratory beads wrongly and it showed that the child has pneumonia yet in reality, it is a

different sickness. So in that case, I have to make a follow up on whether the child has recovered or not and if

not recovered, I have to send him or her to the nearest health facility for further check-up”.

SSP1F1R6” I go to their homes to see how the children are feeling and if the sickness persists, then, I advise the

parents to go to the nearest PHCC or PHCU to get treatment”.

Availability of Diagnostic Tools and Adequate Supply of Antibiotics

The CBDs are able to manage childhood pneumonia in the community, when a reliable supply chain is

available to ensure that they have pneumonia diagnostic tools that are in good working condition and an

adequate supply of antibiotics.

Examples of responses on the Supply Chain Management: indicating availability of devices and medicines for

community management of pneumonia are:

SSP1F1R1 “Yes I have tools for diagnosing pneumonia for example when the parent comes with the child I

check them first and if the respiratory beads show green reading I give the child amoxicillin”.

SSP2F2R4: “They [parents] are aware of CBDs, because we have strong drugs that can help children”.

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SSP2F2R8. “Yeah, for sure, they gave me tools and drugs to treat pneumonia. I am also looking forward to

treat other diseases like malaria, diarrhoea, SAM and other diseases that will be assigned by Malaria

Consortium if need be”.

Theme 2: Current Constraints in Pneumonia Care at the Community Level

Constraints in pneumonia care at community level were identified by responses that were indicative of either

forgetting the iCCM pneumonia guidelines, having lack of or inadequate knowledge and skills to identify

pneumonia, this ranged from responses such as “the common signs of pneumonia are running nose or

excessive crying”.

The CBDs, who were selected to participate in the FGDs, might have included those that had only received the

training on Home Based Management of Malaria and not the entire iCCM training package. Some of the CBDs

had already received the entire iCCM training package, but the responses indicate that iCCM CBDs require

regular supervision and refresher training for CBDs.

Forgotten iCCM Guidelines

Examples of responses of CBDs who demonstrated having forgotten the iCCM pneumonia guidelines, lack of or

inadequate knowledge in identifying signs and symptoms of pneumonia are:

SSP1F1R5 “Vomiting is the most common sign and symptom in a child who is suffering from pneumonia. I

advise mothers if they see this in their children, they should look for treatment”.

SSP1F1R1 “Crying this is the most common sign and symptom in a child who is having pneumonia and I detect

it using respiratory timer and counting beads?”

A small number of CBDs also described the use of UNICEF timer alone or counting beads alone, in a few cases

it was clear that one of the tools had been damaged and the CBD had not received a replacement. It was not

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clear from the responses whether those using counting beads alone were replacing the UNICEF timer with

personal means of timing 60 seconds such as a watch.

We also found that a few CBDs were not using the diagnostic devices correctly, by either using a device alone,

or by treating pneumonia at the green instead of red beads.

Examples of responses on Device Usability and Availability, use of ARI timer or Counting Beads alone include:

SSP1F1R4. “First I welcome the mother of the child and ask the name of the child, age in years and months. The

duration that the sickness has taken and after that I use the respiratory timer to examine the child, that

respiratory timer can show signs of pneumonia”.

SSP1F1R4 “Children under 5 years, I use coloured counting beads to diagnose pneumonia and I check for signs

and symptoms of pneumonia for example high fever, vomiting and if the coloured counting beads shows green

than am made aware that the child has pneumonia”.

SSP1F1R1 “I use coloured counting beads to diagnose pneumonia, for example if it shows green I am sure that

the child has pneumonia, then I give him medicine to take, then I advise the mother to give the child the

medicine during evening hours”.

Constraints with Availability of Diagnostic Tools and Adequate Supply of Antibiotics

The work of the CBDs in diagnosing and managing pneumonia is affected by the availability of pneumonia

diagnostic tools and an adequate supply of antibiotics.

Examples of responses on the community management of pneumonia being affected by the supply of drugs

and devices (supply chain management).

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SSP2F2R8 “Yes they normally bring their children to me for treatment but sometimes I cannot give the needed

support because of lack of drugs”.

SSP2F2R6: “Yes, for me the problem I face now is that the respiratory beads I had got broken, and that has

made my work not easy. I reported it to my supervisor to replace it but no action to date”.

R. Ok so how do you manage to treat pneumonia?

RN [Other participants laughed]

SSP2F2R6. (..............) Sometimes I borrow from my colleagues.

Device Use Constraints

The CBDs expressed a number of challenges related to using the current pneumonia devices, related to their

operability, patient comfort, managing critical patients, these challenges made them and the caregivers lack

confidence in the diagnosis and decision making on whether to treat or not treat the child with antibiotics, the

challenges were:

Examples of Responses on Device Usability Constraints focused on the fact that devices are clumsy or too

cumbersome to use:

SSP1F1R2 “I dislike coloured counting beads, because you can read some and skip the rest and that makes it

difficult for me to diagnose pneumonia”.

SSP1F1R1. “Coloured-counting beads is not good because when I use it, I read some and skip rest, if there is

way of getting good better tools we will be glad to have it. Mostly I would like a tool, which I can read alone

while am looking at the child’s chest, so I prefer to have something like a phone because phone can show exact

time when you are diagnosing pneumonia”.

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Examples highlighting where devices are not durable included:

SSP1F1R2. “It is not reliable to use respiratory timer this is because if you don’t take good care it can fall down

and that can prevent it from working in a normal manner”.

SSP3F3R5 “Well, we were taught on how to use respiratory beads and timer, but sometimes the timer does not

last for long”.

Examples highlighting where devices are not acceptable to the community/do not offer patient comfort:

SSP1F1R5 “I dislike respiratory timer because it disturbs the child, the child may cry while you are diagnosing

pneumonia”.

SSP1F1R6. “Respirator timer is not good because it makes a lot of noise and that scares the child and also it

can’t give exact minutes when diagnosing pneumonia because of the movement of the child. If there is a

chance of getting a watch it could be better to have it, because a watch is simple to use and am sure it will give

accurate results”.

Examples where devices are not acceptable due to low CHW or caregiver confidence in decision-making

include:

SSP1F1R5. “It is not easy to use respiratory timer because sometimes I can’t decide on the results and therefore

I advise parents to go to the PHCC”.

SSP2F2R1. “Respiratory beads and Respiratory timer are not acceptable because they cannot give accurate

results to me and the parents of the child when diagnosing pneumonia”.

Need for Refresher Training

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The CBDs also expressed that they require refresher trainings as pneumonia diagnosis and the use of counting beads and ARI timer is not easy and the skills they are taught in identifying signs and symptoms of pneumonia are easily forgotten. Examples of responses on the need for refresher training included:

SSP2F2R1. “Of course, I need to have refresher training on all four diseases namely pneumonia, diarrhoea,

malaria, SAM because I did not understand them especially pneumonia and how to count respiratory beads”.

SSP2F2R2. “Yes. For me I need additional training on how to count the respiratory beads and respiratory timer.

They normally confuse me when I am counting the beads and the child is breathing at the same time”.

Theme 3: Ideal Tool Characteristics for Pneumonia Diagnosis:

The CBDs gave their opinions on an ideal tool for diagnosis of pneumonia in iCCM, in general they mentioned that the tool has to be acceptable to CBDs and caregivers and be comfortable for the patient

Responses on Ideal Tool Characteristics when considering, Device Usability

Patient Comfort examples:

SSP2F2R2: “I dislike respiratory beads and timer because they scare children and make them cry. The way the

respiratory beads look and the sound the timer makes when diagnosing pneumonia. Therefore, if there is a

way of getting a good one [tool] that does not make noise, it will be good”.

One with Automated diagnosis: colour display, digital display examples:

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SSP1F1R1. “Coloured counting beads is not good because when I use it, I read some and skip rest, if there is

way of getting good better tools we will be glad to have it. Mostly I would like a tool, which I can read alone

while I am looking at the child’s chest”.

Accurate, Simple Tools and Easy to Use examples:

SSP3F3R2 “It [tool] should be accurate and easy to use in the community widely…”

Examples of responses on which tools do the CHWs find to be acceptable to the parents?

SSP2F2R6. “Respiratory beads are not good because you can skip one or two beads when counting to diagnose

pneumonia. That makes our work not good enough, because you can find at the end that the child has

pneumonia but it is the counting that is wrong. So we prefer another tool that will not be counted like beads,

simple to use and it can give accurate results”.

Durable tools example:

SSP2F2R7. I need a change on tools that we are currently using that cannot break easily or get damaged.

Multi-Functional tools example:

SSP3F3R6 If I create mine it will record all the problems, which are holed in your body.

Ideal Tools Designs

The CBDs gave their opinions on what would be an ideal tool designs, and they mentioned tools that would work like: mobile phone (N=14), watch (N=5), radio (N=2), thermometer (N=1) and digital camera (N=1) Examples of responses on ideal tool characteristics, preferred design types

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Mobile phone examples:

SSP2F2R1: “If I were the one to make these tools, I would have made my own tool to look like mobile phone

because mobile phones do not make a lot of sound that scares children”.

Watch examples:

SSP1F1R6. “Respirator timer is not good because it makes a lot of noise and that scares the child and also it

can’t give exact minutes when diagnosing pneumonia because of the movement of the child. If there is a

chance of getting a watch it could be better to have it, because a watch is simple to use and am sure it will give

accurate results”.

Thermometer examples:

SSP1F1R5. If given time, I can make my own tool to look like a thermometer because a thermometer does not

make noise to scare the child

Digital Camera examples:

SSP3F3R2 waaaaaa, I don’t think I can design any tool…………I can make it look like a digital camera

Radio examples:

SSP3F3R5 Yes, it will work like a radio while recording and it can tell you the child has pneumonia

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Discussion

Communication implications

The focus group discussion with iCCM CBDs found that the community management of pneumonia is key for

management of a childhood disease that is acknowledged by the majority of the CBDs (n=18 of 24) to be

common and serious in children under the age of five years in the community. The CBDs expressed that they

had been trained in iCCM and were therefore not only capable but also their role of providing treatment for

childhood pneumonia in the community as a personal responsibility, as mentioned by CBD SSP2F2R3

“SSP2F2R3 Yeah, I attend to all the children in the community because the community selected me to help

children less than 5 years of age. I was trained by ICCM team to give the support needed by my people so; I

have to serve all of them if there are enough drugs.”

This commitment by CBDs to provide community based management for pneumonia is important for a

country like South Sudan which is aiming to reduce children under 5 morbidity and mortality by tackling

common childhood diseases like pneumonia. It has been demonstrated in other countries, for example in

Nepal that it is possible to train illiterate adults to provide effective diagnosis and management of childhood

pneumonia in the community, in addition to facility based management of pneumonia especially in areas

where communities have challenges in accessing primary health care facilities (Dawson, Pradhan et al. 2008,

Marsh, Gilroy et al. 2008).

In our study, we found that though a good number of the CBDs are able to correctly identify the common signs

and symptoms of pneumonia, it was clear from the FGD that a number of the CBDs struggle with both the

identification and management of pneumonia using the iCCM guidelines and using the tools provided; the

counting beads and ARI timer. An example is CBD SSP3F3R6 who expressed an ability to diagnose pneumonia

plus danger signs and prescribes antibiotics, without having to examine the child with the respiratory timer

and counting beads; “SSP3F3R6 I sometimes, check whether a child has high fever, fast breathing and also

vomiting therefore I give amoxicillin tablets without using respiratory timer and coloured counting beads.”.

This indicates a clear indication of forgetting the pneumonia treatment algorithm.

Responses from some of the CBDs indicated improper use of the devices that are provided to aid CBDs in

diagnosing pneumonia, with one CBD indicating that antibiotics are provided at the green beads. The

statement was, “SSP1F1R1 I use coloured counting beads to diagnose pneumonia, for example if it shows

green I am sure that the child has pneumonia, then I give him medicine to take, then I advise the mother to

give the child the medicine during evening hours.” In this case CBD SSP1F1R1 would have been referring to the

beads for the child 2 months to 11 months, which have 49 green beads plus 10 red beads (see picture 4),

when these beads are used correctly with the ARI timer, the CBD would give the antibiotic when their finger

has moved to any of the red beads at the point of the sixty second beep of the ARI timer.

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Picture 4 Counting Beads used in iCCM program, Malaria Consortium-South Sudan

A narrative review of fifteen studies on community case management of pneumonia in Sub Saharan Africa

found that adherence to training guidelines and counting of respiratory rate remains a huge challenge for

community management of pneumonia leading to dangers of antibiotic misuse such as over-treatment or

failure to treat the child (Druetz, Siekmans et al. 2013). The danger of antibiotic misuse when treating

pneumonia in the community was an issue that was raised during the FGDs. CBD SSP2F2R6 expressed that it is

possible to erroneously treat for pneumonia depending on how the CBD performs the counting of the

respiratory rate “SSP2F2R6. Respiratory beads are not good because you can skip one or two beads when

counting to diagnose pneumonia. That makes our work not good enough, because you can find at the end that

the child has pneumonia but it is the counting that is wrong. So we prefer another tool that will not be counted

like beads, simple to use and it can give accurate results.” The comment by this CBD is also supported by a

previous study on the use counting beads in South Sudan, Uganda and Ghana, which found that large spaces

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between beads can lead to inaccurate counting and counting beads was found to be an added task (Noordam,

Barbera Lainez et al. 2014).

The CBDs who participated in the FGDs, requested that training including refresher training on the pneumonia

component and on the correct use of the counting beads and ARI timer should be a priority activity for the

iCCM program. It is also important for CBDs to be periodically supervised to check on whether they are

correctly identifying pneumonia by using the counting beads and ARI timer. Close supervision will also ensure

that the CBDs have adequate supply of antibiotics and that damaged diagnostic tools are replaced.

The FGDs allowed the CBDs to express their opinions on the current pneumonia diagnostics tools and their

ideas of better tools. It emerged that the CBDs are not comfortable using the current diagnostic tools for

counting of the child’s breathing rate and making decisions to give antibiotics. Their concerns on the current

tools is that it is difficult to use both the counting beads and the ARI timer when concentrating on the

movement of the child’s chest, and this concern has been expressed by CHWs in previous studies in South

Sudan, Uganda, and Ghana (Kallander, Tomson et al. 2006, Noordam, Barbera Lainez et al. 2014). The CBDs

also mentioned that quiet often they might move more beads than they intended too, thereby leading to an

erroneously high count, they raised concerns on the durability of the current tools, for example the string of

the counting beads breaks easily and the battery for the ARI timer does not last long. A common concern was

patient comfort, it was indicated that the ARI timer is not easy to use as the tick of the timer frightens

children.

A number of ideas were proposed by the CBDs to improve on the current diagnostic tools. They would like

tools that are easy to use, preferably tools that are automated for example a tool that can give the diagnosis

using colour display, tools that last long, this includes tools with long battery life or those which are not easily

damaged. They would like tools that make the child comfortable when near the CBD.

They design types mentioned for the future tools included mobile phones, this was mentioned as a design

type that could support automation and digital display of results, it was also mentioned that a mobile phone

would not frighten the children. A simple watch was also mentioned as a simpler way of counting rather than

using the ARI timer, which makes a ticking sound that is disturbing to the children and also has a short battery

life. The CBDs would like tools that record and communicate the results to them automatically and it was

suggested that a device that worked like a radio or digital thermometer would be able to self-record and

communicate the results clearly.

Study limitations

The research team experienced several limitations during data collection:

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Cultural aspects, it is possible that female participants might have contributed less during the

discussion (though this is a subjective observation), as the random selection of CBDs meant that

males and female CBDs, and CBDs of different age groups sat together in the same discussion.

Data loss during translation from Dinka to English, this is contributed to, by low to moderate

command of written English by the field staff and lack of knowledge of Dinka language by

supervising staff.

Dinka language is very wordy and this led to a lot of missed words/phrases by the note-taker

during the focus group discussion.

Long distance between Aweil Centre and the Payams, and long distance between the Payams,

such that at the 2nd and 3rd FGDs, participants had to be replaced because some of the

participants failed to arrive in time for the FGD due to long distances that they had to cover

mostly on foot.

Long distances and difficult road terrain between Payams made it a challenge to send face-to-

face invitations to the CBDs prior to the FGDs.

Lack of phone network outside Aweil Centre town, this means that invitations to CBDs could

not be sent via mobile phone, CBDs invitations had to be delivered in person, and after

travelling long distances from Aweil Centre town to the payams it was common not to find

some of the CBDs at their homes to deliver the FGD invitations directly, some of the invitations

were then handed to the CBD supervisors and neighbours, and it was not guaranteed that the

CBD would receive that invitation.

High expectations from the CBDs and the communities in the Payams for incentives to carry out

this research study in the community.

The sampling criteria would have ideally included information on age, education level and

length of work-experience for the CBDs but this information was not available in our database.

The Malaria Consortium iCCM program is updating the database with this information.

Conclusion

It is clear that the iCCM CBDs have experienced challenges in using the counting beads and ARI timer in the

diagnosis and management of pneumonia in the community. The FGD results support the need to evaluate

better tools for pneumonia diagnosis at community level.

It will also be important to gain information on whether gender, age and education level of CBD volunteers

would affect their views on an ideal pneumonia diagnostic tool.

Appendices

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Appendix 1: Stage 1 Research FGD Participants

Ayat East Payam (FGD date: 30-05-14) Mariem West Payam (FGD date:02-06-14) Aweil Town Centre (FGD date: 05-06-14)

Interviewee Age Sex Years of

Experience


experience


experience

I1 31 M 3 I1 27 F 3 I1 28 F 4

I2 32 F 4 I2 29 M 4 I2 35 M 5

I3 25 F 4 I3 34 M 4 I3 23 M 6

I4 23 M 5 I4 21 M 5 I4 24 M 2

I5 22 M 3 I5 26 F 3 I5 22 M 5

I6 34 M 5 I6 27 M 5 I6 25 M 3

I7 28 F 4 I7 38 M 4 I7 30 F 2

I8 21 F 5 I8 30 F 5 I8 32 F 2

Table 1: Stage 1 Research FGD Participants

Appendix 2: FGD Information Sheet (English and Dinka Translation)

Pneumonia Diagnostics Study

Pioc te ye tuany hol ngiec thin

Information Sheet 1 – Community Health Worker Focus Group Discussions

Abang tok 1 – Jam akut lon pial guop

We would like you to help with a research study. This information sheet will tell you what the research involves. Please take your time reading it. It can be read out to you if you choose. Please ask questions and you can talk it over with others if you wish.

Awic ku bin pioc ken kuony ku welke to athor ken yic abi kony ba ke wiic detic, yuol ke kuen bin yen detic, na wiic ke leu bii kuen tene yin. Aleu bin thiec wala bin yen jamic kek koc kok te wiic yin yen

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Overall, the study aims to improve the diagnosis of pneumonia in children under five years of age by community health workers. This is the first stage of the research and will look to capture current challenges in diagnosing pneumonia at the community level and suggestions on characteristics of a tool that could improve the accuracy of pneumonia diagnosis, which is acceptable to the caretakers.

Pioc ken eben eku bi lang ke cok long te ye tuany hol ngiec thin tene mith kor lang run ka dhiec (5) dhuk piny tene koc lon pial guop. Kene eyen ajok tueng ku abi ke jor koc ye men bei ku nyoth dhol puoth leu bi tuany hol ya ngic baai yic ku tekek to puoth leu bi kok la cok yok thin bi hol ya ngic, ku bii marken yi mith nhiar.

Why have I been chosen for the study?

Ye wet ngo yen kueny hen pioc kene yic

You are a community health worker trained in the care and treatment of malaria, pneumonia and diarrhoea in under-five children in a number of locations including in the area where you live. Approximately 24 community health workers will participate in this stage of the study.

Yin raan lon pial guop ci pioc kuony long; Atuoc, hol ku jol a Yac tene mith kor long run ka dhiec(5) dhuk piny te dun reer yin thin ku bei kok thiok kek yin. Te cit ten raan lon pialguop thiarou kun guan (24) abi welken mat pioc ken yic.

What happens if I agree to take part?

Ye ngo bi rot loi te met yen rot thin?

You will be involved in this focus group discussion lasting approximately two hours. Whether you take part is your choice. Participation is completely voluntary; you may choose not to take part or to stop at any time.You will continue to receive the same diagnostic tests and medicines as usual if you do or do not agree to participate. If you participate you will help us find out the best way to diagnose pneumonia in the community.

Yin abi rot mat kek akut jiem ken yic, ku jam abi ya thok te cit tene saat ka rou (2hrs) eyin yin bi ye tak ba rot mat thin acin ke bi gam jamic eben, aleu bin ye kuany lon bin cuk ye raan thin wala ba koc te tek yin yen.

Yin abi nguot yi la tueng ka yi thon ka kun ther ye gam yin ci men waal ku kok luoi cimen there te cin ye gam wala kac gam. Na ba rot mat thin, ke yin abi ok kuony buk dhel path yok bi ok tuany hol ya ngic ten baai.

The Focus Group will be led by a trained member of our research team and will allow you and your colleagues to discuss a number of important issues concerning the diagnosis of pneumonia in your community.

Jam ken abi raan ci pioc kam koc kuan pioc wat nhom, ku abi wek puol bak karil yic apei jamiic te cit te ye tuany hol ngiec thin pandun.

What are the benefits of taking part?

Ye ngo yen ariop raan ci rot mat thin?

If you take part, it is possible that you will only participate in this element of the study; however we cannot be sure at this stage. You will only find out later. Otherwise, there are no direct benefits to you, but this study

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hopes to improve the care of children with pneumonia like those you provide care for in the future.Your travel costs and light refreshments will be provided.

Na ba rot mat thin, ka ke to eku ba jam thin tene ka jiemkek yic ke, ku acin ke det ngicku ten, eke leu bin yen jal yok la ther. Ku dhil ngic lon cin yen ariop ten yin, eepioc ken yen abi lang ke cok ten kuony mith tueny hol kek cimen mith ther ye ke kony. Weu kun cath ku ke thik cam puolyic abi to thin.

What are the possible disadvantages and risks of taking part?

Ye ngo leu bi ya ke rac te met raan rot thin?

There are no added risks involved in participating in this study. Whether you agree or not to take part you will continue to receive same medicines and tests from the project.

Acin ke reec to thin tene koc ci rot mat thin pioc ken yic,te cok yen alon ci yin ye gam wala ca jai ba rot ci met thin , ke yin nguot yi la tueng ke yi lom walk u ka kun luoi tene koc kun luoi.

Will my participation in the study be kept confidential?

Wel cien ba kek luel pioc yic bi kek thian bi ke ci ngic?

Yes. The information will be stored by a number, not by your name. The information will only be available to the researchers working on the study.

Etede, welku abi toou ka ke ye akuen wet ku acie rienku, welke abi reer kek koc lui pioc ken yic.

What will happen to the results of the study?

Ye ngo bi rot loi ten ka bi ben bei thin piocic?

They will be used to improve pneumonia treatment in under-five children care and specifically help in the development of better diagnostic tools for pneumonia. The results will also be published in medical journals. You will not be identified or identifiable in any reports of publications.

Abi luoi bik kuony cok long tuany hol tene mith kor lang run ka dhiec (5) ku abi lang kuony path long la tueng ka ye tuany hol ngic.welke aya kek abi nyuoth athor ye wel wal got thin ku yin aci bi kang ngic te nguth kek thaai

What happens if the research study stops earlier than expected?

Ye ngo bi yien da te le pioc ken koc kamciek ku acie yen to ngoth?

If it does, we will provide you with clear information as to why

Na loi rot ka wek abuk lek wet col yen aloi rot keya?

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Who is doing and paying for the research?

Ye nga loi kene ku ye koc pioc riop?

Malaria Consortium is carrying out the study, with support from the Bill and Melinda Gates Foundation, who are funding the study.

Malaria consortium guop yen yieth kene tueng ku ekuony de yok tene Bill ku Melinda Gates Foundation, ku kek aye pioc ke kuony

If you have any questions at any time, please ask a member of the research team or you can contact:The Research Officer, Pneumonia Diagnostics Project, South Sudan, Malaria Consortium, Telephone: +211 (0)922 400572

Na leng ke wic ba thiec agut cin akol da, ke yi thiec raan tok kam akut koc pioc wala ram kek ok ten: + 211 (0) 922 400 572

Participant Consent Form 1

Research study: A study to capture current constraints in diagnosing pneumonia at the community level and suggestions on characteristics of a tool that could improve the accuracy of pneumonia diagnosis which is acceptable to the caretakers.

I confirm that I have read and understood the information sheet dated _____________________, explaining the above research project and I have had the opportunity to ask questions about the study.

Aca kuen ku aca detic lon na da ka wel to athor ken yic akol niin kua ca thiec ke den looi.

I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason and without any negative consequences. In addition, should I not wish to answer any particular questions, I am free to decline.

Hen aci rot juar epath ba lonken looi e path ku hen a leu ba muol akol ci hen ye tak ke cin ke rec reel thin kua cin raan thiec hen.

Contact number of researcher: +211 (0)922 400 572

Nimira raan yoop ken: +211 (0)922 400 57

[35]

1. I understand that my name will not be linked to the research materials and any personal information that could identify me will be kept strictly confidential. I understand that my responses will be anonymised and that I will not be identified or identifiable in any report, publications or presentations that result from this research.

Aca detic rien cie aci bi mat kek kak lon ken abi ngic, kua bi tou rot.

2. I agree for the data collected from me to be used in future research.

Aca gam bi welka ci loom tene hen luoi akol det.

3. I give permission for this interview to be recorded, to be used only for analysis.

Ka ca luel aca puol bi ke toou bi kek ben caath yiic.

4. I agree to take part in the above research project.

Aca gam bi lang ke luoi ka wic ka yiic.

*To be signed and dated in the presence of the participant.

Abi thanyic ku gat akol niin ka raan kony luoi tou th

Name of participant:

Rin raan lui:

Date:

Akol niin:

Signature/Thumb print:

Thany:

Name of person taking consent:

Rin raan loiken:

Date:

Akol niin:

Signature/Thumb print:

Theny:

SHORT TITLE OF DOCUMENT, Pneumonia Diagnostics Project [36]

Appendix 3: Stage 1 Research FGD Participants Responses

Results

Theme 1: CBDs Knowledge and Management of Pneumonia in the Local Health Situation

Felt Need, Common Illnesses

18 of the 24 respondents gave their views on what they felt was the common childhood disease in the community and 12 of the 24 responded that pneumonia was the most common disease; malaria and diarrhoea were each mentioned by three respondents.

The full responses for the 18 respondents are as follows:

R. Now among three diseases, pneumonia, malaria and diarrhoea which disease is most

common in your village?

Twelve respondents on pneumonia:

SSP1F1R7 ………………Pneumonia is the most common in our area because mothers do not

take good care of the children. This is because, they don’t have knowledge of preventing

pneumonia, like keeping their children in a warm place not to get cough.

SSP2F2R2. Yes, pneumonia is the most common killer disease in the area of my work

because; children are always exposed to cold weather or to dusty living conditions

SSP2F2R4. Yes, I think pneumonia is the most common disease that is killing children less

than 5 years of age because mothers do not know how to protect their children from

pneumonia; it is the most dangerous disease in our community.


SSP2F2R6. [A big smile before responding] Pneumonia is another dangerous disease in

children less than 5 years of age and we are not able to give good treatment, because

enough drugs are not given to us.

SSP2F2R7. In my site, the common disease they seek treatment for is pneumonia because,

children are normally exposed to the cold weather and that makes most mothers to come for

the treatment.

SSP2F2R8. The common disease in my field of work is pneumonia because most children

suffer from cough, chest in drawing, ribs curve, fast breathing which most of them complain

about.

SSP3F3R3 Pneumonia is the most common disease in my area, which affects children under

5years old. This is because some mothers do not take good care of children during cool

weather.

SSP3F3R4 Pneumonia is the most common disease, which affects many children under 5

years old, and this makes them seek treatment from me, to be given amoxicillin tablets. The

reasons being some mothers are illiterate and it is hard to protect their children from bad

weathers.


SSP3F3R5 Pneumonia this is because most parents expose their children to cool weather and

also they do not bath children using hot water and they let their children play in ponds,

which make them to suffer from pneumonia.

SSP3F3R6 Pneumonia is the most common disease in my area, this is because most parents

are not aware of the disease called pneumonia and this makes it hard for parents to take

good care of their children.

SSP3F3R7 [Smiling] Pneumonia is the disease which affects children under 5 years old the

most. This is because mothers do not take good of their children by exposing them to cool

weather and also by bathing them at wrong hours for example at night, also they fail to

cover them using blankets which encourages pneumonia in this area.

SSP3F3R8 Pneumonia is the most common in my area, this is because some parents do not

have knowledge about pneumonia and this encourages pneumonia to be wide spread in my

area and this is why many parents come to me for treatment.

Three respondents on malaria

SSP1F1R4 Well, Malaria is the most common one in this area because of mosquito bites and

also many people lack mosquito nets and they come to me seeking for treatment.

SSP2F2R1…………Malaria is the most common disease because, during wet season, there are

many mosquitoes as a result of rain therefore, mothers fail to protect their children from


mosquito bite by using LLINs because, they do not know what causes malaria but it is

mosquito bites

SSP3F3R1 Malaria, the reason being a lot of mosquitoes during rainy season that causes

malaria in children less than five years of age

Three respondents on diarrhoea:

SSP2F2R3. I think [scratching his head] diarrhoea is the most common disease in my area of

work because many caretakers bring their children less than 5 years of age seeking

treatment for diarrhoea.

SSP2F2R5. To me, the most common disease is diarrhoea because, most of the children eat

dirty food and this causes diarrhoea in children less than 5 years of age.

SSP3F3R2 Diarrhoea this is because of poor sanitation in the areas where parents fail to

practice good sanitation at their homes

CBDs Knowledge on identifying signs and symptoms of pneumonia

Responses of CBDs who demonstrated basic knowledge on identifying and examining a child for the common signs and symptoms of pneumonia:

SSP1F1R2: Fast breathing for instance when mother comes with the child, I am in a position

to know that the child has pneumonia through his or her breathing.


SSPF2R1: Cough is a sign and symptom of pneumonia I have to use respiratory timer and

respiratory beads to examine whether the child has pneumonia or not and if it reads red that

means the child has pneumonia I can give treatment Amoxicillin depending on the child’s

age.

SSP2F2R2: In that case, for me I have to observe or assess the child whether child has fast

breathing and cough or not, and if he or she has those signs and symptoms it means the

child has pneumonia and he or she is eligible to be treated using amoxicillin depending on

the child’s age. However, before that I have to examine the child using respiratory timer and

respiratory beads.

SSP2F2R7: For me I normally use respiratory timer and respiratory beads to find pneumonia

in children less than 5 years of age because, all children with coughs are suspected to have

pneumonia.

SSP3F3R2 For me, the child looks dry, with chest in-drawing, when there are “curves” in the

ribs; and fast breathing, these are common symptoms of pneumonia for a child suffering

from pneumonia and at that point CBDs will be able to know that a child has pneumonia.

SSP3F3R3 Pneumonia has different symptoms such as “ribs curve”, restlessness, chest in

drawing, high fever and also fast breathing these are common symptoms of pneumonia.


SSP1F1R6…”A child with pneumonia has fast breathing and also ribs curve in-wards”

therefore I manage the child by giving him or her medicines to take in my presence and if

child does not start vomiting am sure he/she will get better.

Responses that aimed to describe CBDs knowledge on identification of danger signs in a child with pneumonia

SP1F1R2…I ask about the duration of sickness and whether child can eat something like

food, milk and water. After that I take the respiratory timer or coloured counting beads to

examine for pneumonia, if I discover that the child has pneumonia, I give amoxicillin tablets

for five days.

SSP2F2R6 Chest in drawing is also a common sign and symptom for pneumonia in children

less than 5 years of age. A child with chest in drawing has a danger sign and such a child is

given the first treatment and sent to the nearest health facility for additional check up by

nurse or clinical officers.

SSP3F3R8 The common symptoms of pneumonia are fast breathing, cough, high fever these

are danger signs in a child who has suffered from pneumonia.

The study also found that most CBDs demonstrated that they are able to correctly use the two diagnostic devices, ARI timer and counting beads to count a child’s breathing rate, and make decisions to prescribe antibiotic treatment for pneumonia:

Responses on device usability, correct use of ARI timer and counting beads


SSP1F1R8.……….I look for signs and symptoms of pneumonia, I also use respiratory timer and

coloured counting beads to diagnose pneumonia..

SSP1F1R2 I detect pneumonia when the mother of the child comes to me and explains the

signs of the sickness and I diagnose whether a child is suffering from pneumonia by using

respiratory timer and counting beads.

SP1F1R2…I ask about the duration of sickness and whether child can eat something like

food, milk and water. After that I take the respiratory timer or coloured counting beads to

examine for pneumonia, if I discover that the child has pneumonia, I give amoxicillin tablets

for five days.

SSP2F2R1: For me, I have to welcome the caretaker to sit and I give him or her some drinking

water, then he or she will explain the child’s problem and if it is cough, I have to tell the

mother to breastfeed the child whether the child will cough or not before I decide. Cough is a

sign and symptom of pneumonia I have to use respiratory timer and respiratory beads to

examine whether the child has pneumonia or not and if it reads red that means the child has

pneumonia I can give treatment Amoxicillin depending on the child’s age.

SSP2F2R7: For me I normally use respiratory timer and respiratory beads to find pneumonia

in children less than 5 years of age because, all children with coughs are suspected to have

pneumonia.


SSP2F2R4: Yeah, I count the respiratory beads and respiratory timer to look for pneumonia.

When the count reaches the red point, the child has pneumonia in that case I have to give

treatment to the child by giving him or her amoxicillin tablet.

SSP2F2R1. For me to know a child who is suffering from pneumonia, I normally use

respiratory timer and respiratory beads to come up with accurate results. If the respiratory

beads count stops at red, it means the child has pneumonia; I can now give the treatment

using amoxicillin depending on the child’s age.

SSP2F2R2. …………. Yes I treat pneumonia using amoxicillin, but before treatment I have to

examine the child using respiratory timer and respiratory beads to identify the child’s

sickness.

SSP2F2R3: Yeah they normally come to me asking for treatment and that enables me to use

respiratory timer and counting beads to diagnose pneumonia.

SSP2F2R5. Well, for me, they normally come to me to ask for treatment of pneumonia, and I

have to tell the caretaker to remove the child’s cloth then I begin to examine the child using

respiratory timer while counting beads before giving drugs for pneumonia.

SSP3F3R6 If a child is brought to me, first I welcome parents, and mother and child and then

I ask the name, the age and also the duration of sickness. I have to know the age of the child,

and I take the respiratory beads according to the age, and with the respiratory timer I start

examining the child and if the respiratory timer beeps twice while on red beads, I give


amoxicillin tablets because pneumonia is detected. I give amoxicillin tablets for child to take

one dose before going back to the house.

SSP3F3R7 You look at the child and examine the child using respiratory timer and respiratory

beads and if red sign is reached, pneumonia is said to be present and you treat using

amoxicillin.

SSP3F3R8 I welcome the caregiver and ask him/her some questions, I remove the clothes off

the child and examine using respiratory beads and respiratory timer and treat using

amoxicillin if find that the child has pneumonia

SSP3F3R3.I use respiratory timer and respiratory beads to diagnose pneumonia and detect

whether a child has pneumonia or not and after that I give amoxicillin tablets for the child to

take?

SSP3F3R8. I use both coloured counting beads and respiratory timer to diagnose pneumonia

in children under 5 years old.

SSP3F3R2 I use respiratory timer and coloured counting beads to diagnose pneumonia and

after I find the signs and symptoms of pneumonia I give amoxicillin tablets for treatment.

SSP3F3R3. Yes, I use coloured counting beads and respiratory timer to diagnose pneumonia

before I give amoxicillin tablets for treatment.


SSP2F2R1. I diagnose pneumonia through the explanations given by the caretaker. I ask him

or her for the duration of the sickness; “How long has this child been sick?”

CHWs Accessibility, Community Engagement in iCCM and Community Treatment Options

Responses indicating CBDs, availability and positive attitude towards community management of childhood pneumonia

SSP1F1R5 Yeah I help children ranging from 1 year to 5 year olds who have suffered from

pneumonia and malaria.

SSP1F1R3 I go to their homes and see how the children are feeling, if there is no change, I

advise the parents to seek for further treatment, or I can do another diagnosis to check

whether the child still has pneumonia.

SSP1F1R5 I attend to all children at the community level, because it is my responsibility to do

it and I was chosen by the community to do this work and to improve the lives of their

children.

SSP2F2R3. Yeah, I attend to all the children in the community because the community

selected me to help children less than 5 years of age. I was trained by ICCM team to give the

support needed by my people so; I have to serve all of them if there are enough drugs.


SSP2F2R4. After giving the drug for pneumonia, I go to visit them in order to give more

advice on how they will protect their children from getting pneumonia. For example, to keep

their babies away from cool weather and smoking fire.

SSP2F2R1: Yes, I manage to carry out my entire task assigned to me by Malaria Consortium

because, I have to save my people and that is w

Documents

PNEUMONIA DIAGNOSTICS PROJECT Diagnos… · PNEUMONIA DIAGNOSTICS PROJECT “Pneumonia Diagnostics Project: A study to evaluate and identify improved tools for the measurement of