Abstract
To decrease child mortality due to common but life-threatening illnesses, community health workers (CHWs) are trained to assess, classify and treat sick children. For pneumonia, CHWs are trained to count the respiratory rate of a child with cough and/or difficulty breathing, and determine whether the child has fast breathing or not based on how the child’s breath count relates to age-specific respiratory rate cut-off points. International organizations training CHWs to classify fast breathing realized that many of them faced challenges counting and determining how the respiratory rate relates to age-specific cut-off points. Counting beads were designed to overcome these challenges. This article presents findings from different studies on the utility of these beads, in conjunction with a timer, as a tool to improve classification of fast breathing. Studies conducted by the International Rescue Committee and Save the Children among illiterate CHWs assessed the effectiveness of counting beads to improve both counting and classifying respiratory rate against age-specific cut-off points. These studies found that the use of counting beads enabled and improved the assessment and classification of fast breathing. However, a Malaria Consortium study found that the use of counting beads decreased the accuracy of counting breaths among literate CHWs. Qualitative findings from these studies and two additional studies by UNICEF suggest that the design of the beads is crucial: beads should move comfortably, and a separate bead string, with colour coding, is required for the age groups with different cut-off thresholds—eliminating more complicated calculations. Further research, using standardized protocols and gold standard comparisons, is needed to understand the accuracy of beads in comparison to other tools used for classifying pneumonia, which CHWs benefit most from each different tool (i.e. disaggregating data by levels of literacy and numeracy) and what the impact is on improving appropriate treatment for pneumonia.
Highlights
Because of the overall complexity of diagnosis, the still staggering mortality, lack of diagnostic aids and the growing problem of antibiotic resistance for pneumonia, there is an urgent need for more robust data on tools for pneumonia diagnosis
Accurate assessment of fast breathing is crucial as selected children [children 2–11 months of age with a respiratory rate (RR) of 50 or more breaths/min and children 12–59 months of age with a RR of 40 or more] are classified as having pneumonia based on their breathing rate and require immediate treatment with antibiotics (Pio 2003; World Health Organization (WHO) and United Nations Children Fund (UNICEF) 2005, 2011)
Does the use of beads improve the ability of community health workers (CHWs), those with limited or no literacy and numeracy, to correctly classify fast breathing?
Summary
Because of the overall complexity of diagnosis, the still staggering mortality, lack of diagnostic aids and the growing problem of antibiotic resistance for pneumonia, there is an urgent need for more robust data on tools for pneumonia diagnosis. There are two steps in detecting whether a child has fast breathing: (1) a CHW needs to visually count a child’s breath for 1 min and (2) the CHW has to determine how the child’s breath count relates to age-specific respiratory cut-off points (WHO and UNICEF 2011). Accurate assessment of fast breathing is crucial as selected children [children 2–11 months of age with a respiratory rate (RR) of 50 or more breaths/min and children 12–59 months of age with a RR of 40 or more] are classified as having pneumonia based on their breathing rate and require immediate treatment with antibiotics (Pio 2003; WHO and UNICEF 2005, 2011). 66% illiterate 6 months prior 6 months prior Part of research Age-specific þ colour coded.
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