Health System Considerations for Community-Based Implementation of Automated Respiratory Counters to Identify Childhood Pneumonia in 5 Regions of Ethiopia: A Qualitative Study

Document Type : Original Article


1 UNICEF Supply Division Innovation Unit, Copenhagen, Denmark

2 School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada

3 UNICEF Ethiopia Country Office, Addis Ababa, Ethiopia

4 Global Programmes and Research, SingHealth Duke-NUS Global Health Institute, Duke-NUS, Singapore, Singapore

5 Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia

6 Frontieri Consult, Addis Ababa, Ethiopia

7 Child and Community Health Unit, Health Programme Group, UNICEF, New York City, NY, USA

8 UNICEF Supply Division, Copenhagen, Denmark

9 Digital Health and Health Information Systems Unit, Health Programme Group, UNICEF, New York City, NY, USA

10 Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden


In Ethiopia, childhood pneumonia is diagnosed in primary healthcare settings by measuring respiratory rate (RR) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. Our aim was to identify health system-level lessons from implementing two automated RR counters, Children’s Automated Respiration Monitor (ChARM) by Phillips® and Rad-G by Masimo®, to provide considerations for integrating such devices into child health programmes and health systems. This study was part of an initiative called the Acute Respiratory Infection Diagnostic Aids (ARIDA).

Key informant interviews (KIIs) were conducted with 57 participants (health workers in communities and facilities, trainers of health workers, district management, and key decision-makers) in five regions of Ethiopia. Data were analyzed in ATLAS.ti using thematic content analysis and themes were categorized using the Tanahashi bottleneck analysis.

All participants recommended scaling up the ARIDA initiative nationally as part of Integrated Management of Newborn and Childhood Illness (IMNCI) in primary healthcare. Health workers perceived the devices as: time saving, acceptable by parents and children, and facilitating diagnosis and referrals. Health workers perceived an increased demand for services and reduced numbers of sick children not seeking care. Participants recommended increasing the number of devices distributed and health workers trained. Strengthening drug supply chains, improving oxygen gas availability, and strengthening referral networks would maximize perceived benefits. While training improved knowledge, more supportive supervision, integration with current guidelines and more guidance related to community engagement was recommended.

Automatic RR counters for the decentralized diagnosis of childhood pneumonia could have positive impact on improving the quality of diagnosis and management of pneumonia in children. However, the study has shown that a health system approach is required to ensure all steps along the pneumonia pathway are adequate, including drug and oxygen supply, community engagement, health worker training and support, and referral pathways.


  1. Perin J, Mulick A, Yeung D, et al. Global, regional, and national causes of under-5 mortality in 2000-19: an updated systematic analysis with implications for the sustainable development goals. Lancet Child Adolesc Health. 2022;6(2):106-115. doi:1016/s2352-4642(21)00311-4
  2. World Health Organization (WHO). Revised WHO Classification and Treatment of Pneumonia in Children at Health Facilities: Evidence Summaries. Geneva: WHO; 2014. Accessed August 31, 2019.
  3. Baker K, Alfvén T, Mucunguzi A, et al. Performance of four respiratory rate counters to support community health workers to detect the symptoms of pneumonia in children in low resource settings: a prospective, multicentre, hospital-based, single-blinded, comparative trial. EClinicalMedicine. 2019;12:20-30. doi:1016/j.eclinm.2019.05.013
  4. Johansson EW, Nsona H, Carvajal-Aguirre L, Amouzou A, Hildenwall H. Determinants of Integrated Management of Childhood Illness (IMCI) non-severe pneumonia classification and care in Malawi health facilities: analysis of a national facility census. J Glob Health. 2017;7(2):020408. doi:7189/jogh.07.020408
  5. Uwemedimo OT, Lewis TP, Essien EA, et al. Distribution and determinants of pneumonia diagnosis using Integrated Management of Childhood Illness guidelines: a nationally representative study in Malawi. BMJ Glob Health. 2018;3(2):e000506. doi:1136/bmjgh-2017-000506
  6. Ngocho JS, Horumpende PG, de Jonge MI, Mmbaga BT. Inappropriate treatment of community-acquired pneumonia among children under five years of age in Tanzania. Int J Infect Dis. 2020;93:56-61. doi:1016/j.ijid.2020.01.038
  7. Olson D, Preidis GA, Milazi R, et al. Task shifting an inpatient triage, assessment and treatment programme improves the quality of care for hospitalised Malawian children. Trop Med Int Health. 2013;18(7):879-886. doi:1111/tmi.12114
  8. Spence H, Baker K, Wharton-Smith A, et al. Childhood pneumonia diagnostics: community health workers' and national stakeholders' differing perspectives of new and existing aids. Glob Health Action. 2017;10(1):1290340. doi:1080/16549716.2017.1290340
  9. Baker K, Maurel A, Ward C, et al. Automated respiratory rate counter to assess children for symptoms of pneumonia: protocol for cross-sectional usability and acceptability studies in Ethiopia and Nepal. JMIR Res Protoc. 2020;9(3):e14405. doi:2196/14405
  10. Ward C, Baker K, Marks S, et al. Determining the agreement between an automated respiratory rate counter and a reference standard for detecting symptoms of pneumonia in children: protocol for a cross-sectional study in Ethiopia. JMIR Res Protoc. 2020;9(4):e16531. doi:2196/16531
  11. Helldén D, Baker K, Habte T, et al. Does chest attachment of an automated respiratory rate monitor influence the actual respiratory rate in children under five? Am J Trop Med Hyg. 2020;102(1):20-27. doi:4269/ajtmh.19-0458
  12. Källander K, Ward C, Smith H, et al. Usability and acceptability of an automated respiratory rate counter to assess childhood pneumonia in Nepal. Acta Paediatr. 2020;109(6):1207-1220. doi:1111/apa.15108
  13. Ward C, Baker K, Smith H, et al. Usability and acceptability of an automated respiratory rate counter to assess children for symptoms of pneumonia: a cross-sectional study in Ethiopia. Acta Paediatr. 2020;109(6):1196-1206. doi:1111/apa.15074
  14. Alwadhi V, Sarin E, Kumar P, et al. Measuring accuracy of plethysmography based respiratory rate measurement using pulse oximeter at a tertiary hospital in India. Pneumonia (Nathan). 2020;12:4. doi:1186/s41479-020-00067-2
  15. Tack B, Vita D, Mbaki TN, Lunguya O, Toelen J, Jacobs J. Performance of automated point-of-care respiratory rate counting versus manual counting in children under five admitted with severe febrile illness to Kisantu hospital, DR Congo. Diagnostics (Basel). 2021;11(11):2078. doi:3390/diagnostics11112078
  16. Floyd J, Wu L, Hay Burgess D, Izadnegahdar R, Mukanga D, Ghani AC. Evaluating the impact of pulse oximetry on childhood pneumonia mortality in resource-poor settings. Nature. 2015;528(7580):S53-59. doi:1038/nature16043
  17. Rees CA, Basnet S, Gentile A, et al. An analysis of clinical predictive values for radiographic pneumonia in children. BMJ Glob Health. 2020;5(8):e002708. doi:1136/bmjgh-2020-002708
  18. Requejo JH, Bryce J, Barros AJ, et al. Countdown to 2015 and beyond: fulfilling the health agenda for women and children. Lancet. 2015;385(9966):466-476. doi:1016/s0140-6736(14)60925-9
  19. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018;392(10160):2203-2212. doi:1016/s0140-6736(18)31668-4
  20. English M, Irimu G, Agweyu A, et al. Building learning health systems to accelerate research and improve outcomes of clinical care in low- and middle-income countries. PLoS Med. 2016;13(4):e1001991. doi:1371/journal.pmed.1001991
  21. Tolla HS, Asemere YA, Desale AY, et al. Changes in the availability of medical oxygen and its clinical practice in Ethiopia during a national scale-up program: a time series design from thirty-two public hospitals. BMC Pediatr. 2021;21(1):451. doi:1186/s12887-021-02844-4
  22. ARIDA (Acute Respiratory Infection Diagnostic Aid). Accessed September 7, 2020.
  23. Kallander K, Baker K, Tarekegn H, Getachew D, Tariku Fantaye A. Acute Respiratory Infection Diagnostic Aids (ARIDA) for children under five years when used in the community setting: Study protocol for the acceptability evaluation. 2018.
  24. Baker K, Ward C, Maurel A, et al. Usability and acceptability of a multimodal respiratory rate and pulse oximeter device in case management of children with symptoms of pneumonia: a cross-sectional study in Ethiopia. Acta Paediatr. 2021;110(5):1620-1632. doi:1111/apa.15682
  25. Källander K, Ward C, Smith H, et al. Usability and acceptability of an automated respiratory rate counter to assess childhood pneumonia in Nepal. Acta Paediatr. 2020;109(6):1207-1220. doi:1111/apa.15108
  26. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. Geneva: World Health Organization; 2013.
  27. World Health Organization (WHO). World Health Report: Health Systems Improving Performance. Geneva: WHO; 2000.
  28. Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ. 1978;56(2):295-303.
  29. World Health Organization, Alliance for Health Policy and Systems Research. Embedded Health Policy and Systems Research. Published 2018. Accessed November 15, 2020.
  30. Heath H, Cowley S. Developing a grounded theory approach: a comparison of Glaser and Strauss. Int J Nurs Stud. 2004;41(2):141-150. doi:1016/s0020-7489(03)00113-5
  31. The Federal Democratic Republic of Ethiopia, Ministry of Health. National Medical Oxygen and Pulse Oximetry Scale Up Road Map (2016-2020/21). 2016.
  32. Tesfaye SH, Gebeyehu Y, Loha E, Johansson KA, Lindtjørn B. Pulse oximeter with integrated management of childhood illness for diagnosis of severe childhood pneumonia at rural health institutions in Southern Ethiopia: results from a cluster-randomised controlled trial. BMJ Open. 2020;10(6):e036814. doi:1136/bmjopen-2020-036814
  33. McCollum ED, King C, Deula R, et al. Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi. Bull World Health Organ. 2016;94(12):893-902. doi:2471/blt.16.173401
  34. Farnsworth SK, Böse K, Fajobi O, et al. Community engagement to enhance child survival and early development in low- and middle-income countries: an evidence review. J Health Commun. 2014;19 Suppl 1(sup1):67-88. doi:1080/10810730.2014.941519
  35. Ameha A, Karim AM, Erbo A, et al. Effectiveness of supportive supervision on the consistency of integrated community cases management skills of the health extension workers in 113 districts of Ethiopia. Ethiop Med J. 2014;52 Suppl 3:65-71.
  36. Akafu W, Daba T, Tesfaye E, Teshome F, Akafu T. Determinants of trust in healthcare facilities among community-based health insurance members in the Manna district of Ethiopia. BMC Public Health. 2023;23(1):171. doi:1186/s12889-023-15124-w
  37. Guddu DK, Demissie DB. Patient satisfaction with referral service and associated factors among public hospitals in and around Addis Ababa, Central Ethiopia. SAGE Open Med. 2022;10:20503121221089443. doi:1177/20503121221089443
  38. Ethiopian Public Health Institute, Ethiopian Ministry of Health. Ethiopia Service Provision Assessment 2021-2022: Preliminary Report. Addis Ababa, Ethiopia; 2022.
  39. Ansermino JM, Dunsmuir D, Karlen W, Gan H, Dumont GA. Are respiratory rate counters really so bad? Throwing the baby out with the bath water. EClinicalMedicine. 2019;16:14. doi:1016/j.eclinm.2019.09.013
  40. Baker K, Alfvén T, Källander K. More work needs to be done to ensure that better pneumonia diagnostics aids are developed and launched to better support frontline health workers-a response to "Are respiratory rate counters really so bad" by Ansermino et al. EClinicalMedicine. 2019;16:15. doi:1016/j.eclinm.2019.09.012
  41. Amirav I, Lavie M. Rethink respiratory rate for diagnosing childhood pneumonia. EClinicalMedicine. 2019;12:6-7. doi:1016/j.eclinm.2019.06.013
  42. Tools for Integrated Management of Childhood Illnesses. Accessed March 20, 2022.
  43. Sarin E, Kumar A, Alwadhi V, Saboth P, Kumar H. Experiences with use of a pulse oximeter multimodal device in outpatient management of children with acute respiratory infection during COVID pandemic. J Family Med Prim Care. 2021;10(2):631-635. doi:4103/jfmpc.jfmpc_1410_20
  • Receive Date: 13 May 2022
  • Revise Date: 07 June 2023
  • Accept Date: 30 September 2023
  • First Publish Date: 02 October 2023