title: Assessing the Quality of Care for Pneumonia in Integrated Community Case Management: A Cross-Sectional Mixed Methods Study.
abstract: BACKGROUND
  Pneumonia is the leading infectious cause of mortality in children under five worldwide. Community-level interventions, such as integrated community case management, have great potential to reduce the burden of pneumonia, as well as other diseases, especially in remote populations. However, there are still questions as to whether community health workers (CHW) are able to accurately assess symptoms of pneumonia and prescribe appropriate treatment. This research addresses limitations of previous studies using innovative methodology to assess the accuracy of respiratory rate measurement by CHWs and provides new evidence on the quality of care given for children with symptoms of pneumonia. It is one of few that assesses CHW performance in their usual setting, with independent re-examination by experts, following a considerable period of time post-training of CHWs.
  
  
  METHODS
  In this cross-sectional mixed methods study, 1,497 CHW consultations, conducted by 90 CHWs in two districts of Luapula province, Zambia, were directly observed, with measurement of respiratory rate for children with suspected pneumonia recorded by video. Using the video footage, a retrospective reference standard assessment of respiratory rate was conducted by experts. Counts taken by CHWs were compared against the reference standard and appropriateness of the treatment prescribed by CHWs was assessed. To supplement observational findings, three focus group discussions and nine in depth interviews with CHWs were conducted.
  
  
  CONCLUSIONS
  The findings support existing literature that CHWs are capable of measuring respiratory rates and providing appropriate treatment, with 81% and 78% agreement, respectively, between CHWs and experts. Accuracy in diagnosis could be strengthened through further training and the development of improved diagnostic tools appropriate for resource-poor settings.
authors.affiliation: Malaria Consortium, Mansa, Luapula Province, Zambia.
authors.forename: Chomba
authors.initials: C
authors.lastname: Sinyangwe
authors.affiliation: Malaria Consortium, London, United Kingdom.
authors.forename: Kirstie
authors.initials: K
authors.lastname: Graham
authors.affiliation: Malaria Consortium, London, United Kingdom.
authors.forename: Sarala
authors.initials: S
authors.lastname: Nicholas
authors.affiliation: The Nuffield Centre for International Health & Development, University of Leeds, Leeds, United Kingdom.
authors.forename: Rebecca
authors.initials: R
authors.lastname: King
authors.affiliation: Malaria Consortium, Mansa, Luapula Province, Zambia.
authors.forename: Samuel
authors.initials: S
authors.lastname: Mukupa
authors.affiliation: Malaria Consortium, London, United Kingdom.
authors.forename: Karin
authors.initials: K
authors.lastname: Källander
authors.affiliation: Malaria Consortium, London, United Kingdom.
authors.forename: Helen
authors.initials: H
authors.lastname: Counihan
authors.affiliation: Malaria Consortium, Kampala, Uganda.
authors.forename: Mark
authors.initials: M
authors.lastname: Montague
authors.affiliation: Malaria Consortium, Kampala, Uganda.
authors.forename: James
authors.initials: J
authors.lastname: Tibenderana
authors.affiliation: Malaria Consortium, London, United Kingdom.
authors.forename: Prudence
authors.initials: P
authors.lastname: Hamade
mesh_terms: D003150:Community Health Workers; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D011014:Pneumonia / Q000175:diagnosis* / Q000453:epidemiology* / Q000473:pathology / Q000628:therapy; D011787:Quality of Health Care; D012424:Rural Population; D015024:Zambia