title: Revisiting community case management of childhood pneumonia: perceptions of caregivers and grass root health providers in Uttar Pradesh and Bihar, northern India.
abstract: BACKGROUND
  Community-acquired pneumonia (CAP) is the leading cause of under-five mortality globally with almost one-quarter of deaths occurring in India.
  
  
  OBJECTIVE
  To identify predisposing, enabling and service-related factors influencing treatment delay for CAP in rural communities of two states in India. Factors investigated included recognition of danger signs of CAP, health care decision making, self-medication, treatment and referral by local practitioners, and perceptions about quality of care.
  
  
  METHODS
  Qualitative research employing case studies (CS) of care-seeking, key informant interviews (KII), semi-structured interviews (SSI) and focus group discussions (FGD) with both video presentations of CAP signs, and case scenarios. Interviews and FGDs were conducted with parents of under-five children who had suffered CAP, community health workers (CHW), and rural medical practitioners (RMP).
  
  
  RESULTS
  From September 2013 to January 2014, 30 CS, 43 KIIs, 42 SSIs, and 42 FGDs were conducted. Recognition of danger signs of CAP among caregivers was poor. Fast breathing, an early sign of CAP, was not commonly recognized. Chest in-drawing was recognized as a sign of serious illness, but not commonly monitored by removing a child's clothing. Most cases of mild to moderate CAP were brought to RMP, and more severe cases taken to private clinics in towns. Mothers consulted local RMP directly, but decisions to visit doctors outside the village required consultation with husband or mother-in-law. By the time most cases reached a public tertiary-care hospital, children had been ill for a week and treated by 2-3 providers. Quality of care at government facilities was deemed poor by caregivers.
  
  
  CONCLUSIONS
  To reduce CAP-associated mortality, recognition of its danger signs and the consequences of treatment delay needed to be better recognized by caregivers, and confidence in government facilities increased. The involvement of RMP in community based CAP programs needs to be investigated further given their widespread popularity.
authors.affiliation: Department of Pediatrics, King George's Medical University, Lucknow, India.
authors.forename: Shally
authors.initials: S
authors.lastname: Awasthi
authors.affiliation: The School of Anthropology, University of Arizona, Tucson, United States of America.
authors.forename: Mark
authors.initials: M
authors.lastname: Nichter
authors.affiliation: Department of Pediatrics, King George's Medical University, Lucknow, India.
authors.forename: Tuhina
authors.initials: T
authors.lastname: Verma
authors.affiliation: UNICEF's Office for Uttar Pradesh, Lucknow, India.
authors.forename: Neeraj Mohan
authors.initials: NM
authors.lastname: Srivastava
authors.affiliation: Department of Community Medicine, King George's Medical University, Lucknow, India.
authors.forename: Monica
authors.initials: M
authors.lastname: Agarwal
authors.affiliation: Department of Community Medicine, King George's Medical University, Lucknow, India.
authors.forename: Jai Vir
authors.initials: JV
authors.lastname: Singh
mesh_terms: D000328:Adult; D000368:Aged; D017028:Caregivers; D002675:Child, Preschool; D003153:Community Health Services; D019058:Community Networks; D017714:Community-Acquired Infections / Q000453:epidemiology / Q000628:therapy; D019468:Disease Management; D005260:Female; D006760:Hospitalization; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000453:epidemiology / Q000628:therapy*; D063128:Tertiary Health Care; D055815:Young Adult