title: The use of counting beads to improve the classification of fast breathing in low-resource settings: a multi-country review.
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.
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden camielle.noordam@maastrichtuniversity.nl.
authors: Aaltje Camielle
authors: AC
authors: Noordam
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
authors: Yolanda
authors: Y
authors: Barberá Laínez
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
authors: Salim
authors: S
authors: Sadruddin
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
authors: Pabla Maria
authors: PM
authors: van Heck
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
authors: Alex Opio
authors: AO
authors: Chono
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
authors: Geoffrey Larry
authors: GL
authors: Acaye
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
authors: Victor
authors: V
authors: Lara
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA
authors: Agnes
authors: A
authors: Nanyonjo
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
authors: Charles
authors: C
authors: Ocan
authors: Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, Malaria Consortium, plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda and Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden Health Section, United Nations Children Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, International Rescue Committee (IRC), 122 East 42nd Street, New York, NY 10168, USA, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA, UNICEF Supply Division, Oceanvej 10-12, 2100 København Ø, Denemarken, International Rescue Committee (IRC), Plot 7 Lower East Naguru Road, P.O. Box 24672, Kampala, Uganda, UNICEF Tamale Field Office, Norrip Building Complex, Bolgatanga Road, P.O. Box 1098, Tamale, Ghana, Population Service International (PSI), Whitefield Place, School Lane, Westlands, P.O. Box 14355-00800, Nairobi, Kenya, Malaria Consortium, Plot 25, Upper Naguru East road, P.O Box 8045, Kampala, Uganda, Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden, Save the Children, 501 Kings Highway East, Suite 400, Fairfield CT 06825, USA
authors: Karin
authors: K
authors: Källander
mesh_terms: D000349:Africa / Q000453:epidemiology; D046688:Child Mortality; D002675:Child, Preschool; D003150:Community Health Workers / Q000193:education; D019937:Diagnostic Techniques and Procedures / Q000295:instrumentation*; D006801:Humans; D008288:Malaria; D011014:Pneumonia / Q000175:diagnosis*; D012119:Respiration
keywords: Acute respiratory infection; case management; child health; community care; diagnosis