Care For Acute Respiratory Infections Research Articles

C-reactive protein testing in primary care for acute respiratory infections: a cost-effective strategy to mitigate antimicrobial resistance across different income settings

C-reactive protein testing in primary care for acute respiratory infections: a cost-effective strategy to mitigate antimicrobial resistance across different income settings

Effectiveness of BNT162b2 BA.4/5 bivalent mRNA vaccine against a range of COVID-19 outcomes in a large health system in the USA: a test-negative case–control study

XBB-related omicron sublineages have recently replaced BA.4/5 as the predominant omicron sublineages in the USA and other regions globally. Despite preliminary signs of immune evasion of XBB sublineages, few data exist describing the real-world effectiveness of bivalent COVID-19 vaccines, especially against XBB-related illness. We aimed to investigate the effectiveness of the Pfizer--BioNTech BNT162b2 BA.4/5 bivalent vaccine against both BA.4/5-related and XBB-related disease in adults aged 18 years or older. In this test-negative case-control study, we estimated the effectiveness of the BNT162b2 BA.4/5 bivalent vaccine using data from electronic health records of Kaiser Permanente Southern California health system members aged 18 years or older who received at least two doses of the wild-type COVID-19 mRNA vaccines. Participants sought care for acute respiratory infection between Aug 31, 2022, and April 15, 2023, and were tested for SARS-CoV-2 via PCR tests. Relative vaccine effectiveness (≥2 doses of wild-type mRNA vaccine plus a BNT162b2 BA.4/5 bivalent booster vs ≥2 doses of a wild-type mRNA vaccine alone) and absolute vaccine effectiveness (vs unvaccinated individuals) was estimated against critical illness related to acute respiratory infection (intensive care unit [ICU] admission, mechanical ventilation, or inpatient death), hospital admission, emergency department or urgent care visits, and in-person outpatient encounters with odds ratios from logistic regression models adjusted for demographic and clinical factors. We stratified vaccine effectiveness estimates for hospital admission, emergency department or urgent care visits, and outpatient encounters by omicron sublineage (ie, likely BA.4/5-related vs likely XBB-related), time since bivalent booster receipt, age group, number of wild-type doses received, and immunocompromised status. This study is registered with ClinicalTrials.gov (NCT04848584). Analyses were conducted for 123 419 encounters (24 246 COVID-19 cases and 99 173 test-negative controls), including 4131 episode of critical illness (a subset of hospital admissions), 14 529 hospital admissions, 63 566 emergency department or urgent care visits, and 45 324 outpatient visits. 20 555 infections were BA.4/5 related and 3691 were XBB related. In adjusted analyses, relative vaccine effectiveness for those who received the BNT162b2 BA.4/5 bivalent booster compared with those who received at least two doses of a wild-type mRNA vaccine alone was an additional 50% (95% CI 23-68) against critical illness, an additional 39% (28-49) against hospital admission, an additional 35% (30-40) against emergency department or urgent care visits, and an additional 28% (22-33) against outpatient encounters. Waning of the bivalent booster from 0-3 months to 4-7 months after vaccination was evident for outpatient outcomes but was not detected for critical illness, hospital admission, and emergency department or urgent care outcomes. The relative effectiveness of the BNT162b2 BA.4/5 bivalent booster for XBB-related infections compared with BA.4/5-related infections was 56% (95% CI 12-78) versus 40% (27-50) for hospital admission; 34% (21-45) versus 36% (30-41) against emergency department or urgent care visits; and 29% (19-38) versus 27% (20-33) for outpatient encounters. By mid-April, 2023, individuals previously vaccinated only with wild-type vaccines had little protection against COVID-19-including hospital admission. A BNT162b2 BA.4/5 bivalent booster restored protection against a range of COVID-19 outcomes, including against XBB-related sublineages, with the most substantial protection observed against hospital admission and critical illness. Pfizer.

Results of a regional immunoprophylaxis program for children at risk of a severe course of respiratory syncytial virus infection with palivizumab in the Republic of Bashkortostan

Background. Palivizumab has been successfully used in many countries worldwide to prevent respiratory syncytial infection in children at risk of severe infection. Despite the drug use experience in some regions of the Russian Federation, evidence on the outcomes of specific immunoprophylaxis in children from risk groups is scarce.
 Aim. To assess the results of the regional immunoprophylaxis program for children at high risk of severe respiratory syncytial virus infection (RSVI) with palivizumab in the Republic of Bashkortostan.
 Materials and methods. A single-center retrospective cohort study was conducted at the Catamnesis Cabinet of the Republican Clinical Perinatal Center, Ufa. A total of 516 preterm infants born before the full 35 weeks of gestation and who reached the age of 1 year of life between April 2020 and April 2022 were included in the study. Group 1 (palivizumab+) included 250 infants who received at least one immunization against RSVI at a dose of 15 mg/kg; Group 2 (palivizumab-) included 266 infants without immunization. In both groups, the percentage of children admitted to the clinic for acute respiratory infections and hospitalized for lower respiratory infections was determined.
 Results. It was found that children born at a gestational age of 32 weeks had immunoprophylaxis more often than children born at a gestational age of 3235 weeks (58.1% vs 37.2%; p0.001); also, they more often received 35 injections of palivizumab (32.9% vs 17.9%; p=0.018). The proportion of children who were admitted to the clinic for ARI was lower among those immunized than among those not immunized: 63.6% vs 82.0% (p0.001; relative risk RR 0.77, 95% confidence interval CI 0.690.86). Of children who received 12 injections of palivizumab, 70.2% sought medical care for acute respiratory infections versus 53.3% of children who received 35 injections (p0.001; RR 1.51, 95% CI 1.151.98). Among the immunized infants, the percentage of children admitted to the hospital for bronchitis was significantly lower: 24.0% vs 31.6% (p=0.045; RR 0.74, 95% CI 0.550.99). The most significant effect of palivizumab was demonstrated in children born at the gestational age of 32 weeks or less, who received 35 injections of the drug.
 Conclusion. The study demonstrated the effectiveness of the regional RSVI immunoprophylaxis program with palivizumab in children in the first year of life at risk for severe infection in the Republic of Bashkortostan.

Опыт применения назальных форм интерферона в лечении и профилактике острых респираторных инфекций

По данным ВОЗ, каждый третий житель планеты ежегодно обращается за медицинской помощью по поводу острой респираторной инфекции. Результаты многих исследований показывают, что коррекция иммунных процессов в очаге воспаления дает больший эффект, чем влияние на иммунокомпетентные клетки кровеносного русла (при системном использовании препаратов). Поэтому логичным подходом к терапии респираторных вирусных инфекций, поражающих респираторный эпителий, является интраназальное применение препаратов интерферонов, которые обеспечивают противовирусное, иммуномодулирующее и противобактериальное действие в месте развития инфекционного процесса. В доступной литературе имеется достаточное количество клинических исследований, посвященных изучению эффективности назальных и аэрозольных форм интерферона альфа при острых респираторных вирусных инфекциях (ОРВИ). В них показано, что рекомбинантный интерферон альфа является эффективным препаратом для лечения и профилактики ОРВИ. Его применение сокращает сроки клинического выздоровления больных, уменьшает степень выраженности клинических симптомов заболевания, позволяет избежать манифестации заболевания. Также препараты интерферонов могут применяться как средство предотвращения ОРВИ и гриппа.

Disparities in mothers\u2019 healthcare seeking behavior for common childhood morbidities in Ethiopia: based on nationally representative data

BackgroundChildhood morbidities such as diarrhea and pneumonia are the leading causes of death in Ethiopia. Appropriate healthcare-seeking behavior of mothers for common childhood illnesses could prevent a significant number of these early deaths; however, little nation-wide research has been conducted in Ethiopia to assess mothers’ healthcare-seeking behavior for their under five children.MethodsThe study used the Ethiopian Demographic and Health Surveys (EDHS) data. The EDHS is a cross sectional survey conducted in 2016 on a nationally representative sample of 10,641 respondents. The main determinants of care-seeking during diarrhea and acute respiratory infection (ARI) episodes were assessed using multiple logistic regression analyses while adjusting for complex survey design.ResultsOnly 43% and 35% of households sought medical attention for their children in episodes of diarrhea and ARI, respectively, during a reference period of 2 weeks before the survey. The odds of seeking care for diarrhea are lower for non-working mothers versus working mothers. The likelihood of seeking care for diarrhea or ARI is higher for literate fathers compared to those with no education. The place of delivery for the child, receiving postnatal checkup and getting at least one immunization in the past determined the likelihood of seeking care for ARI, but not for diarrhea. The odds of seeking care are higher for both diarrhea and ARI among households that are headed by females and where mothers experienced Intimate Partner Violence (IPV) violence. Religion and types of family structure are also significant factors of seeking care for diarrhea episodes, but not for ARI.ConclusionsThe findings call for more coordinated efforts to ensure equitable access to health care services focusing on mothers living in deprived household environment. Strengthening partnerships with public facilities, private health care practitioners, and community-based organizations in rural areas would help further improve access to the services.

IFNL4 Genotypes Predict Clearance of RNA Viruses in Rwandan Children With Upper Respiratory Tract Infections.

Polymorphisms in the interferon lambda gene locus (IFNL) such as the IFNL4 genetic variants rs12979860 and rs368234815 are predictive of resolution of hepatitis C virus infection, but information about the impact of these variants in other infections is scarce. This study aimed at determining the potential impact of IFNL4 variation for the clearance of respiratory tract pathogens in Rwandan children (≤5 years old, n = 480) seeking medical care for acute respiratory infections. Nasopharyngeal swabs were retrieved from all children at the first hospital referral and from 161 children at follow-up visits 2 weeks later. The swabs were analyzed for pathogens by real-time PCR and for host cell IFNL4 genotype at rs12979860 and rs368234815. Approximately 1/3 of the children were homozygous for the rs12979860 T allele and the rs368234815 ΔG allele, which are overrepresented in subjects of African descent. These IFNL4 variants were significantly associated with reduced clearance of RNA viruses. Our results suggest that IFNL4 genotypes that are common among subjects of African descent may determine inefficacious clearance of RNA viruses from the respiratory tract.

Quality Of Care For Acute Respiratory Infections During Direct-To-Consumer Telemedicine Visits For Adults.

In direct-to-consumer telemedicine, physicians treat patients through real-time audiovisual conferencing for common conditions such as acute respiratory infections. Early studies had mixed findings on the quality of care provided during direct-to-consumer telemedicine and were limited by small sample sizes and narrow geographic scopes. Using claims data for 2015-16 from a large national commercial insurer, we examined the quality of antibiotic management in adults with acute respiratory infection diagnoses at 38,839 direct-to-consumer telemedicine visits, compared to the quality at 942,613 matched primary care visits and 186,016 matched urgent care visits. In the matched analyses, we found clinically similar rates of antibiotic use, broad-spectrum antibiotic use, and guideline-concordant antibiotic management. However, direct-to-consumer telemedicine visits had less appropriate streptococcal testing and a higher frequency of follow-up visits. These results suggest specific opportunities for improvement in direct-to-consumer telemedicine quality.

Implementation research on community health workers' provision of maternal and child health services in rural Liberia.

ObjectiveTo assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme.MethodsThe Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation.FindingsBetween 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly.ConclusionWe identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes.

Health inequality on results and access indicators for children in Mexico: analysis of national health surveys

To analyze inequalities in health care indicators of children 0 to 9 years old in Mexico reporting gap and gradient measures. Cross-sectional analysis of national health surveys in 2000, 2006 and 2012, measuring absolute and relative gap measures as well as the Slope Index of Inequality for four health care indicators (vaccination, care for acute respiratory infections, care for acute diarrheal diseases, and care for accidents) with socioeconomic stratification, as well as absolute gaps by sex, urbanicity and ethnic background. Between 2000 and 2012, immunological equity was reached in Mexico, as well as elimination in the socioeconomic gap related to care for accidents; nevertheless, there is a persistent socioeconomic gap of care for acute respiratory infections that is also there regarding rural residence and indigenous population. In Mexico, there is a trend to the elimination of socioeconomic differences in the probability of receiving adequate health care among children, although some socioeconomic gaps remain in particular related to provision of services that require more participation of health personnel. There is a need to ensure homogenous access to effective services for all.

Using Clinical Vignettes to Assess Quality of Care for Acute Respiratory Infections.

Overprescribing of antibiotics for acute respiratory infections (ARIs) is common. Our objective was to develop and validate a vignette-based method to estimate clinician ARI antibiotic prescribing. We surveyed physicians (n = 78) and retail clinic clinicians (n = 109) between January and September 2013. We surveyed clinicians using a set of ARI vignettes and linked the responses to electronic health record data for all ARI visits managed by these clinicians during 2012. We then created a new measure of antibiotic prescribing, the comprehensive ARI management rate. This was defined as not prescribing antibiotics for antibiotic-inappropriate diagnoses and prescribing guideline-concordant antibiotics for antibiotic-appropriate diagnoses (and also included appropriate use of streptococcal testing for the pharyngitis vignettes). We compared the vignette-based and chart-based comprehensive ARI management at the clinician level. We then identified the combination of vignettes that best predicted comprehensive ARI management rates, using a partitioning algorithm. Responses to 3 vignettes partitioned clinicians into 4 groups with chart-based comprehensive ARI management rates of 61% (n = 121), 50% (n = 47), 31% (n = 12), and 22% (n = 7). Responses to 3 clinical vignettes can identify clinicians with relatively poor quality ARI antibiotic prescribing. Vignettes may be a mechanism to target clinicians for quality improvement efforts.

Can the rolling cross-sectional survey design be used to estimate the effectiveness of influenza vaccines?

IntroductionObservational studies of influenza vaccine effectiveness often study persons seeking medical care for acute respiratory infection (ARI). We conducted a pilot study to determine if vaccine effectiveness could be estimated in the general population with a novel rolling cross-sectional survey sampling design and laboratory confirmation of influenza. MethodsCross-sectional samples were selected weekly from defined populations in Marshfield, Wisconsin and Monroe County, New York from January through April, 2011 (12 weeks). Persons were telephoned and asked about the occurrence of ARI in the past week. Nasal and throat swabs were obtained from consenting individuals with ARI and tested by real-time reverse transcription polymerase chain reaction (RT-PCR). Vaccine effectiveness (VE) was defined as (100×[1−OR]) for vaccination in a logistic regression model that adjusted for age, calendar week, and site. The comparison group included all study participants without RT-PCR confirmed influenza, including those who were not ill. ResultsStudy personnel contacted 9537 (62%) of 15,303 persons sampled; the primary analysis included 5678 subjects. Of these, 193 (3%) reported an ARI and agreed to be tested for influenza; 13 (7%) were influenza positive. The adjusted effectiveness of the influenza vaccine was 1% (95% confidence limits −239–70%). ConclusionsThe rolling cross-sectional design is methodologically feasible and may be useful as a complement to clinic-based VE studies. This pilot study did not have sufficient power to detect significant vaccine effectiveness during a mild influenza season, but this approach may facilitate rapid estimation of VE in a pandemic setting when normal patterns of health care utilization are disrupted.

Attainments and limitations of an early childhood programme in Colombia.

The Growth and Development Monitoring Programme is a longstanding early childhood social intervention in Colombia. The programme's goal is the prevention and early identification of problems affecting children's health and nutrition. To achieve this aim, the programme's basic strategy is to educate parents about the overall health care of infants. The objective of this study is to measure the impact of this programme on children's nutrition and health status and maternal child-care practices. To address potential selection bias, we employ quasi-experimental techniques. This article uses data from the Demographic Health Survey of 2010. The evidence suggests that the programme improved immunization status and the likelihood of health care for acute respiratory infection or fever. As expected, the programme has a greater impact on children from among the poorest people in the country. In the most advanced regions and for the beneficiaries of private health care, the effects of the programme have tended to be negligible. In this sense, our central policy recommendation is to optimize the programme for the poorest households in the country.

Prevalence and clinical characteristics of human respiratory syncytial virus in Chinese adults with acute respiratory tract infection

Respiratory syncytial virus (RSV) is a leading cause of respiratory tract illnesses worldwide. Although the prevalence and clinical manifestations of the two subtypes, RSV‐A and RSV‐B, have been studied in some detail in infants and young children, they have not been determined in adults. To evaluate the prevalence of the RSV subtypes and disease severity between RSV‐A and RSV‐B infections in adults, nasal and throat swabs that were collected from patients ≥15 years old who sought medical care for acute respiratory infections at the Fever Clinic of the Peking Union Medical College Hospital in Beijing, China between May 2005 and April 2010. The samples were tested for RSV infection using PCR and sequencing analysis. RSV was detected in 95 (1%) of the adult patients, of whom 53 (55.8%) were positive for RSV‐A and 42 (44.2%) for RSV‐B. The incidence of RSV infections increased with age (χ2 = 37.17, P = 1.66E−07). Demographic data and clinical manifestations of RSV‐A were similar to those of RSV‐B. Although RSV‐A and RSV‐B co‐circulated during the 2005–2006 and 2008–2009 seasons, RSV‐A was predominant in the 2006–2008 seasons, whereas RSV‐B was predominant in the 2009–2010 season. Upper respiratory tract infections were diagnosed in most RSV‐infected patients (n = 80, 84.2%), and three patients suffered from pulmonary infection. This is the first study to provide data on the prevalence and clinical manifestations of RSV subgroups among Chinese adults with fever and acute illness, over five successive epidemic seasons. J. Med. Virol. 85:348–353, 2013. © 2012 Wiley Periodicals, Inc.

Antibiotic Prescriptions Are Associated with Increased Patient Satisfaction With Emergency Department Visits for Acute Respiratory Tract Infections

Health care providers cite patient satisfaction as a common reason for prescribing antibiotics for viral acute upper respiratory infections (URIs), even though quality performance measures emphasize nonantibiotic treatment for these conditions. In a secondary analysis of a cluster-randomized trial to test a combined patient and physician educational intervention to reduce antibiotic prescribing for URIs, the authors examined whether satisfaction is greater among patients diagnosed with URIs who are prescribed antibiotics in emergency department (ED) settings. This was a follow-up telephone survey of 959 patients who received care for acute respiratory infections at any of eight Veterans Administration (VA) hospital EDs or eight location-matched non-VA hospital EDs around the United States. Patients reported their satisfaction with the amount of time spent in the ED, the explanation of treatment, the provider treatment, and overall satisfaction on a five-point Likert scale. The primary measure of effect was the association between antibiotic prescription and visit satisfaction, adjusted for patient and visit characteristics. Antibiotic treatment was significantly associated with increased overall visit satisfaction in non-VA EDs (adjusted odds ratio [OR] = 1.97, 95% confidence interval [CI] = 1.23 to 3.17), but not VA EDs (adjusted OR = 1.13, 95% CI = 0.81 to 1.58). Patients managed in non-VA EDs who received antibiotics were also significantly more likely to be satisfied with the explanation of treatment and the manner in which they were treated by the provider. Antibiotic prescriptions are associated with increased overall patient satisfaction in non-VA, but not VA, ED visits for URIs. Continued efforts to reduce unnecessary prescriptions in these settings must address ways to maintain patient satisfaction and still reduce antibiotic prescriptions.

Are doctors and nurses associated with coverage of essential health services in developing countries? A cross-sectional study.

BackgroundThere is broad policy consensus that a shortage of doctors and nurses is a key constraint to increasing utilization of essential health services important for achieving the health Millennium Development Goals. However there is limited research on the quantitative links between health workers and service coverage rates. We examined the relationship between doctor and nurse concentrations and utilization rates of five essential health services in developing countries.MethodsWe performed cross-national analyses of low- and middle-income countries by means of ordinary least squares regression with coverage rates of antenatal care, attended delivery, caesarean section, measles immunization, tuberculosis case diagnosis and care for acute respiratory infection as outcomes. Doctor, nurse and aggregate health worker (sum of doctors and nurses) concentrations were the main explanatory variables.ResultsNurses were associated with utilization of skilled birth attendants (P = 0.02) and doctors were associated with measles immunization rates (P = 0.01) in separate adjusted analyses. Aggregate health workers were associated with the utilization of skilled birth attendants (P < 0.01) and measles immunization (P < 0.01). Doctors, nurses and aggregate health workers were not associated with the remaining four services.ConclusionA range of health system and population-level factors aside from health workers influences coverage of health services in developing countries. However, it is also plausible that health workers who are neither doctors nor nurses, such as clinical officers and community health workers, may be providing a substantial proportion of health services. The human resources for health research agenda should be expanded beyond doctors and nurses.

Breastfeeding Prevents Severe Disease in Full Term Female Infants With Acute Respiratory Infection

Breastfeeding is a well-known protective factor against severe respiratory tract infections. Recently, a gender specific role for human milk has been described in very low birth weight infants and neonates: breast milk protected girls but not boys. To determine whether the protective effect of breastfeeding on the severity of acute respiratory infections in full term infants is different for girls and boys. A prospective cross-sectional study of infants seeking medical care for acute respiratory infection. The protective role of breastfeeding against viral pneumonia and hospitalization were assessed by univariate and multivariate analyses. Analyses were adjusted for important confounders. A total of 323 patients were enrolled in this study. Breastfeeding protected girls against pneumonia and hospitalization, but did not protect boys. Nonbreastfeeding females were particularly susceptible to severe acute respiratory infections. Breastfeeding had a protective effect against severe disease in infant girls experiencing their first symptomatic respiratory infection. Nonbreastfeeding females are at significant risk for severe acute lung disease and should be targeted intensively by breastfeeding campaigns.

Improving Care for Acute Respiratory Infections: Better Systems, Not Better Microbiology

Improving Care for Acute Respiratory Infections: Better Systems, Not Better Microbiology

Acceptability of a Bilingual Interactive Computerized Educational Module in a Poor, Medically Underserved Patient Population

We evaluated the acceptability and impact of an audiovisual, bilingual, interactive computer module relating to appropriate antibiotic use. In winter 2001, adults seeking urgent care for acute respiratory infections at an inner-city urgent care clinic were invited to complete the computer module and survey (N = 296). After responding to questions about their symptoms, patients were provided information about their illness and appropriate antibiotic use, and then asked several questions about the acceptability of the module. The main outcomes, reflecting qualities known to enhance diffusion of innovations, were “learning something new about colds and flu” and trusting the computer information. Spanish-language respondents (16%) were much less likely to report prior computer experience, more likely to need help, and strongly preferred answering to a person compared with English-language respondents. In multivariable analysis, Spanish-language respondents were more likely to report learning something new (OR = 5.0; 95% CI: 2.0, 12.4) and trusting the information (OR = 2.5; 95% CI: 1.0, 6.0). We conclude that an interactive computer module was well received among a medically underserved urgent care clinic population. Benefits appear greatest among populations having the least experience with this medium.

Factors influencing private health providers’ technical quality of care for acute respiratory infections among under-five children in rural West Bengal, India

In many developing countries, private health practitioners provide a significant portion of curative care for diseases which are of public health importance. Currently, health sector reform efforts in these countries are fostering increased participation of private providers in the delivery of health services, including those of public health importance. Guaranteeing good technical quality of care is critical to the process. However, little is known about private providers’ technical quality of care (disease management practices) and the factors influencing these services. The purpose of this study was to contribute information on this topic. The study was conducted among private providers in rural West Bengal, India and focused on providers’ disease management practices for acute respiratory infections (ARI) among under-five children. World Health Organization (WHO) guidelines for ARI case management were used as the expected standard of care. Observations of patient–provider encounters and interviews with the providers and mothers were the main sources of data. The study found that private health providers in rural West Bengal have inadequate technical quality of care. The problem was related both to low levels of performance (limited potential) and inconsistency in performance (within-provider variation). Limited potential for good technical quality for ARI among the providers was related to lack of knowledge (technical incompetence). One of the important factors influencing within-provider variation was patient load. Since rural private providers operate on a fee-for-service payment system, there are incentives related to seeing many patients. The study concluded that to bring about sustainable improvements in private providers’ ARI disease management practices, training programs and interventions that improved compliance were necessary.

Overcoming Cultural Barriers to Patient Care for Acute Respiratory Infections in Young Children

Overcoming Cultural Barriers to Patient Care for Acute Respiratory Infections in Young Children