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.

Development of a novel device for objective respiratory rate measurement in low-resource settings

“…Beyond 65 min –1 , the device need only display a ‘high’ readout, indicating tachypnoea and the need for antibiotic treatment. Previous studies have shown that CHWs sometimes have a difficult time interpreting numerical results and applying the RR appropriately to the ICMI treatment algorithm to determine appropriate candidates for antibiotic treatment 24. As such it has been recommended by the Unicef TPP that a device that provides automated results with a high level of treatment decision support is preferable 16 19.…”

Point-of-care diagnostics to improve maternal and neonatal health in low-resource settings

“…When measured by primarily illiterate community health workers in Uganda and South Sudan, it was found the rate of correctly classifying fast breathing in children increased from 27% to 68% when using the counting beads. 321 While counting techniques have shown great improvements in the ability to accurately detect fast breathing, automated devices that decrease the time burden on health care workers could further improve pneumonia detection. Some wearable, continuous infant monitoring devices have been developed (for example, the Rest Devices’ Mimo and Snuza® Hero MD ), but these devices remain prohibitively expensive for use in low-resource settings, as the per device costs range from$150 - $300.…”

“…(b) Bead strand used by UNICEF that is non-specific for ages 0–5 years and each color is made up of 10 beads for ease of counting. Reprinted from Reference 321 under the terms of Creative Commons Attribution License.…”

“…All rights reserved. Sepsis image reproduced from Reference 391 under the terms of Creative Commons Attribution License. HIV image provided courtesy Alere Inc. Congenital Syphilis image provided courtesy Alere Inc. Pneumonia image reproduced from Reference 321 under the terms of Creative Commons Attribution License. …”

“… Pneumonia image reproduced from Reference 321 under the terms of Creative Commons Attribution License. …”