Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings

Simkovich, Suzanne M.; Underhill, Lindsay J.; Kirby, Miles A.; Crocker, Mary E.; Goodman, Dina; McCracken, John P.; Thompson, Lisa; Díaz-Artiga, Anaité; Castañaza-Gonzalez, Adly; Garg, Sarada; Balakrishnan, Kalpana; Thangavel, Gurusamy; Rosa, Ghislaine; Peel, Jennifer L.; Clasen, Thomas; McCollum, Eric D.

doi:10.1164/rccm.202104-1013oc

Cited by 12 publications

(6 citation statements)

References 44 publications

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“…HAPIN was designed to be a proof-of-concept, efficacy trial. Indeed, the investigators conducted at least 18 months of formative field research [ 20 , 21 , 22 , 23 , 24 ] or leveraged ongoing research [ 25 ] to identify study settings with low population density and low ambient air pollution. Formative activities included training personnel in ultrasound measurements to assess gestational period that met eligibility criteria [ 26 ], developing procedures for stove installation and training in stove use [ 10 ], assessing methods of fuel delivery to assure a continuous fuel supply, developing and implementing behavioral messages for intervention adherence, including monitoring temperature of biomass fuel stoves in intervention homes [ 13 ] and collecting outcome data within specific time windows [ 10 ].…”

Section: Discussionmentioning

confidence: 99%

Facing the Realities of Pragmatic Design Choices in Environmental Health Studies: Experiences from the Household Air Pollution Intervention Network Trial

Checkley¹,

Hossen²,

Rosa³

et al. 2022

IJERPH

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Objective: Household Air Pollution Intervention Network (HAPIN) investigators tested a complex, non-pharmacological intervention in four low- and middle-income countries as a strategy to mitigate household air pollution and improve health outcomes across the lifespan. Intervention households received a liquefied petroleum gas (LPG) stove, continuous fuel delivery and regular behavioral reinforcements for 18 months, whereas controls were asked to continue with usual cooking practices. While HAPIN was designed as an explanatory trial to test the efficacy of the intervention on four primary outcomes, it introduced several pragmatic aspects in its design and conduct that resemble real-life conditions. We surveyed HAPIN investigators and asked them to rank what aspects of the design and conduct they considered were more pragmatic than explanatory. Methods: We used the revised Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) to survey investigators on the degree of pragmatism in nine domains of trial design and conduct using a five-point Likert rank scale from very explanatory (1) to very pragmatic (5). We invited 103 investigators. Participants were given educational material on PRECIS-2, including presentations, papers and examples that described the use and implementation of PRECIS-2. Results: Thirty-five investigators (mean age 42 years, 51% female) participated in the survey. Overall, only 17% ranked all domains as very explanatory, with an average (±SD) rank of 3.2 ± 1.4 across domains. Fewer than 20% of investigators ranked eligibility, recruitment or setting as very explanatory. In contrast, ≥50% of investigators ranked the trial organization, delivery and adherence of the intervention and follow-up as very/rather explanatory whereas ≤17% ranked them as rather/very pragmatic. Finally, <25% of investigators ranked the relevance of outcomes to participants and analysis as very/rather explanatory whereas ≥50% ranked then as rather/very pragmatic. In-country partners were more likely to rank domains as pragmatic when compared to investigators working in central coordination (average rank 3.2 vs. 2.8, respectively; Wilcoxon rank-sum p < 0.001). Conclusion: HAPIN investigators did not consider their efficacy trial to be rather/very explanatory and reported that some aspects of the design and conduct were executed under real-world conditions; however, they also did not consider the trial to be overly pragmatic. Our analysis underscores the importance of using standardized tools such as PRECIS-2 to guide early discussions among investigators in the design of environmental health trials attempting to measure efficacy.

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Section: Discussionmentioning

confidence: 99%

Facing the Realities of Pragmatic Design Choices in Environmental Health Studies: Experiences from the Household Air Pollution Intervention Network Trial

Checkley¹,

Hossen²,

Rosa³

et al. 2022

IJERPH

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“…We evaluated the accessibility of resources to diagnose and treat severe pneumonia in children using a geographical information system (GIS) and found that only 43-69% of the population lived within 30 minutes’ travel time of a health facility equipped to care for severe pneumonia in selected rural areas in Guatemala, India, Peru, and Rwanda. 43 Use of GIS to identify locations for setting up pulse oximetry shortened travel time by 18 minutes across sites. 43 …”

Section: Potential Of Open Source Databasesmentioning

confidence: 99%

“… 43 Use of GIS to identify locations for setting up pulse oximetry shortened travel time by 18 minutes across sites. 43 …”

Section: Potential Of Open Source Databasesmentioning

confidence: 99%

Integrating non-communicable disease prevention and control into maternal and child health programmes

Simkovich

Foeller

Tunçalp

et al. 2023

BMJ

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“…Clinical risk assessment is poorly taught and practised, with respiratory signs being one of the most consistently missed elements of existing IMCI practice [53][54][55]. Pulse oximeters are rarely available or used in primary care settings [40,43,46,[56][57][58] despite inclusion in WHO primary care guidelines and "priority medical device" lists [59,60]. Other factors to consider include caregiver understanding of treatment, signs of deterioration, and when to return for review; and caregiver ability to return for urgent or routine review, taking into account geographical distance, and the availability and affordability of transport.…”

Section: Implications and Interpretationmentioning

confidence: 99%

Which children with chest-indrawing pneumonia can be safely treated at home, and under what conditions is it safe to do so? A systematic review of evidence from low- and middle-income countries

Wilkes¹,

Graham²,

Walker³

et al. 2022

J Glob Health

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Background WHO pneumonia guidelines recommend that children (aged 2-59 months) with chest indrawing pneumonia and without any “general danger sign” can be treated with oral amoxicillin without hospital admission. This recommendation was based on trial data from limited contexts whose generalisability is unclear. This review aimed to identify which children with chest-indrawing pneumonia in low- and middle-income countries can be safely treated at home, and under what conditions is it safe to do so. Methods We searched MEDLINE, EMBASE, and PubMed for observational and interventional studies of home-based management of children (aged 28 days to four years) with chest-indrawing pneumonia in low- or middle-income countries. Results We included 14 studies, including seven randomised trials, from a variety of urban and rural contexts in 11 countries. Two community-based and two hospital-based trials in Pakistan and India found that home treatment of chest-indrawing pneumonia was associated with similar or superior treatment outcomes to hospital admission. Evidence from trials (n = 3) and observational (n = 6) studies in these and other countries confirms the acceptability and feasibility of home management of chest-indrawing pneumonia in low-risk cases, so long as safeguards are in place. Risk assessment includes clinical danger signs, oxygen saturation, and the presence of comorbidities such as undernutrition, anaemia, or HIV. Pulse oximetry is a critical risk-assessment tool that is currently not widely available and can identify severely ill patients with hypoxaemia otherwise possibly missed by clinical assessment alone. Additional safeguards include caregiver understanding and ability to return for review. Conclusions Home treatment of chest-indrawing pneumonia can be safe but should only be recommended for children confirmed to be low-risk and in contexts where appropriate care and safety measures are in place.

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Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings

Cited by 12 publications

References 44 publications

Facing the Realities of Pragmatic Design Choices in Environmental Health Studies: Experiences from the Household Air Pollution Intervention Network Trial

Facing the Realities of Pragmatic Design Choices in Environmental Health Studies: Experiences from the Household Air Pollution Intervention Network Trial

Integrating non-communicable disease prevention and control into maternal and child health programmes

Which children with chest-indrawing pneumonia can be safely treated at home, and under what conditions is it safe to do so? A systematic review of evidence from low- and middle-income countries

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