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The purpose of this health facility survey was to evaluate how the ARI (Acute Respiratory Infection) Program actually works in an everyday, non-research setting. We surveyed 33 clinics and aid posts, including 223 children with ARI and 104 health workers. In this primary health care setting, health workers diagnosed 37% of ARI cases as pneumonia, compared to 69% in the same children assessed independently by trained ARI surveyors using Papua New Guinea case management, which defines fast breathing as > or = 40 per minute for children 1 month to 5 years of age. Agreement between health workers and surveyors was reasonably good (kappa > or = 0.6) for the history of symptoms, but was poor (kappa < 0.3) for diagnoses, treatments and signs such as respiratory rate (RR) and chest indrawing. Health workers counted the RR in only 14% of cases in the survey. In essence, we found that health workers in Simbu are not practising ARI case management. We conclude that case management guidelines which define fast breathing as a rate of > or = 40 per minute classify too many obviously well children as pneumonia. Furthermore, we encountered difficulties in measuring RR accurately, and documented marked inter-observer variation in this setting. Consequently, we are concerned about the ARI Program's excessive reliance on RR and rigid protocols at the expense of clinical sense. Case management guidelines developed for aid post orderlies or village health workers may need to be modified, or used differently by experienced nurses at health centres, who recognize sick children better than by following a standardized protocol. Despite better overall ARI knowledge and practice by nurses, we could demonstrate an impact of the ARI Training Program only on community health workers (CHWs). In order to improve ARI clinical practice, we recommend that the ARI Program in PNG initiates regular on-site clinical supervision of nurses and CHWs at health centres.
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PMID:Evaluation of the ARI program: a health facility survey in Simbu, Papua, New Guinea. 794 57

In 1992, 320 mothers were interviewed in a Rawalpindi hospital to identify which of the signs and symptoms they saw in their own children were most consistently linked with a clinical diagnosis of pneumonia as opposed to common cold. A related goal was to determine whether mothers could correctly judge the actual presence or absence of two major pneumonia signs--fast breathing and chest indrawing. The mothers were predominantly poor and 43% were illiterate. The study sample was composed of four matched groups: (1) mothers of 80 children with pneumonia, most with severe disease, interviewed after the child was referred to the ward; (2) mothers of 80 such children interviewed in the outpatient clinic prior to any discussion of the pneumonia diagnosis; (3) mothers of 80 children with common cold; and (4) mothers of 80 'well' children. Results showed that when mothers were interviewed in the clinic, their perception that a child had fast breathing and/or chest indrawing was highly correlated with pneumonia (sensitivity 64%, specificity 90%). Mothers were even more likely to say that a child had these signs after the pneumonia diagnosis had been conveyed, suggesting that interaction with doctors influenced their views. Fast breathing was better recognized than chest indrawing, and accurate diagnosis of both signs was better among mothers having prior experience with childhood pneumonia. The data suggest that even in the absence of formal ARI education, a majority of Pakistani mothers attending hospitals in indigent areas can recognize these two signs in their own children. However, the seriousness of the signs and their connection with pneumonia should be stressed in education campaigns since a high percentage of children had chest indrawing (a late sign of severe disease) by the time they were brought to the hospital.
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PMID:Mothers' perceptions of severe pneumonia in their own children: a controlled study in Pakistan. 820 45

Fifty mothers of children attending a hospital outpatient clinic with non-severe pneumonia (fast breathing but no chest indrawing) were interviewed in depth. Maternal perceptions and practices with clinical significance were documented. Results showed that most mothers initially tried "heat-producing" home remedies designed to counter the "coldness" of the disease, allowed only 2 days for any particular allopathic medicine to work, and did not go to the same practitioner twice. When mothers were asked what had alarmed them enough to come to the hospital, the symptoms named most frequently were persistent severe cough and high fever, inability to sleep and excessive crying. Fast breathing was spontaneously mentioned by only a few, although when questioned, 32/50 said that they had noticed it. The mothers who had prior experience with child pneumonia were more likely to notice fast breathing and also came to the hospital earlier than those who were inexperienced. Relatively higher levels of maternal education and income were suggestively associated with bringing a female child rather than a male child for pneumonia treatment. Fewer than half of the mothers knew where air goes when a person breathes in and where the lungs are located. Most held treatment preferences at odds with the protocols proposed for the national ARI program currently being initiated in Pakistan, e.g. they said that a doctor should use a stethoscope, should prescribe suspensions rather than tablets and should give injections. This study provides baseline data on attitudes and behaviors that can either be built on in that program or addressed through public education campaigns.
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PMID:Maternal perceptions of pneumonia and pneumonia signs in Pakistani children. 821 Dec 79

One hundred cases of pneumonia with chest indrawing were treated according to the treatment protocol of the ARI control programme. The majority of children were > 2 months old (85 per cent) with male predominance (61 per cent). All cases with severe pneumonia survived. A mortality rate of 7.7 per cent was seen in cases of very severe pneumonia. Three children in the severe pneumonia group deteriorated on benzyl penicillin to very severe pneumonia but subsequently improved on chloramphenicol. Six patients were treated as cases of Staphylococcal pneumonia and one of them died. Thirteen children (21.3 per cent) in the severe pneumonia group required oxygen for breathing rates > 70 per minute. Seventy-four per cent in the very severe pneumonia group required administration of IV fluids. Blood counts did not prove to be of help in differentiating the children at risk of dying. There was no significant difference in roentgenographic findings in the two groups. Congestive cardiac failure was the most common complication, seen in 33.3 per cent of cases of the very severe pneumonia group. The duration of stay was significantly less in cases of severe pneumonia (4.21 +/- 1.59 days) as compared to very severe pneumonia (9.35 +/- 2.39 days). The data from this study suggest that the treatment protocol for the ARI control programme for hospitalized children is reasonably effective and can be implemented in small hospitals.
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PMID:ARI control programme: results in hospitalized children. 827 36

In a prospective study of acute lower respiratory infections (ALRI), at the University College Hospital, UCH, Ibadan, 35 viral pathogens were identified by immunofluorescence (IF) techniques from 24 (68.6%) respiratory specimens from 35 hospitalised pre-school children. The respiratory diagnoses comprised croup, bronchiolitis, pneumonia and pleural effusion. The viral identifications comprised 14 (40.0%) of parainfluenza virus type 3, 10 (28.6%) of respiratory syncytial virus (RSV), 5 (14.3%) of influenza virus type A, 4 (11.4%) of parainfluenza virus type 1 and 2 (5.7%) of influenza virus type B. Two or more viral agents were identified in as many as 10 (41.7%) of the 24 IF positive secretions, 8 (80.0%) of which were obtained from children with features of protein energy malnutrition. Twenty subjects had both virological and bacteriological analyses, in 8 (40.0%) of whom co-existing bacteraemia was identified. Four (50.0%) of these blood culture positive subjects, also had features of overt malnutrition. Neither the age nor the sex was significantly related to the viral identifications (P > 0.81 & 0.35 respectively). Similarly, the final respiratory diagnoses were not significantly related to the viral identifications despite the seemingly suggestive relationship between a diagnosis of croup and parainfluenza identifications as well as that between pneumonia and RSV/parainfluenza type 3 identifications. It is concluded that the high proportion of positive viral identifications is a pointer to the importance of viruses as possible primary etiological agents of ALRI in countries of the West African sub-region and perhaps in developing countries of other tropical subregions. The multiplicity of microbial identifications (viruses and bacteria), seen in malnourished children, may explain the clinical severity of ALRI in the same group of children. The usefulness of IF as a rapid diagnostic tool, as well as the potential implications of our findings on ARI control in developing countries, are discussed.
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PMID:Viral pathogens of acute lower respiratory infections in pre-school Nigerian children and clinical implications of multiple microbial identifications. 851 76

From December, 1992 to February, 1993, 100 consecutively admitted children between 2-24 months of age with pneumonia were studied. They were diagnosed and treated according to the National ARI Control Programme case management guidelines. Of the total, 74 were under one year of age. Seventeen children had very severe pneumonia, 77 severe pneumonia and 6 simple pneumonia. Sixty children had radiological evidence of pneumonia, 89 responded to standard recommended treatment and only 11% required a change of therapy. There were no deaths. Only 6 mothers of these 100 children had practiced exclusive breast feeding. Low socioeconomic status, illiteracy and malnutrition were the other risk factors. In this study all types of pneumonia were more common in children under one year of age and radiology did not appear to be essential for its diagnosis. The National ARI Control guidelines for diagnosis and management of hospitalized children are simple, useful and effective.
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PMID:Clinical, nutritional and radiological features of pneumonia. 896 96

This study, conducted between May 9 and May 19, 1994 in twenty health centres in Addis Ababa, looks at the quality of care provided for children presenting to public sector health centres in Addis Ababa with ARI and/or diarrhoea. As has been documented in other countries, both developing and developed, inappropriate prescription of medications is common in Addis Ababa. Forty four per cent of children received useless or potentially harmful drugs; in 97 of 99 cases of "sore throat", antibiotics were prescribed; only 14 of 116 children with the diagnosis of "common cold" received no medication. While 88 percent of children with diarrhoea received ORS, and 39 per cent of children with pneumonia were given appropriate medications, few caretakers knew how to use them properly. Caretakers' knowledge of appropriate home care of children with ARI and diarrhoea (feeding, use of fluids and indication for return to the clinic) was found to be deficient. Causes for poor quality of care are discussed, and recommendations for solving some of the problems identified, and for further research, are presented.
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PMID:Management of children with ARI and/or diarrhoea in Addis Ababa, Ethiopia. 916 38

"Child Survival Activities in Turkey" are: growth monitoring programs, expanded programs of immunization (elimination of neonatal tetanus, reducing morbidity and mortality of measles, eradication of polio), control of diarrheal diseases (oral rehydration therapy), control of deaths from pneumonia (ARI), baby-friendly hospitals initiative and promotion of breast-feeding, salt iodization programs, elimination of vitamin A deficiency, safe motherhood projects, and phenylketonuria screening programs. Furthermore, family planning, nutrition and education of the mother were among the subjects covered because of their role in child health. The activities, aims and strategies related to these programs are taken up separately. The status of child health and some of the child survival and development programs (growth monitoring program, expanded program of immunization, control of diarrheal diseases, control of deaths from pneumonia, baby-friendly hospitals initiative and promotion of breast-feeding) are discussed in the article.
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PMID:The status of child health and child survival and development programs in Turkey. 967 27

In southern Vietnam it is not uncommon that children under 5 years of age die from pneumonia. Reduction of severity and mortality has to rely on proper case management by mothers and health workers on both grass root level and referral level. The responsibility of training of clinical skills of ARI case management in the southern provinces of Vietnam has been delegated to Pediatric Hospital N1 (PHN1) Ho Chi Minh City (HCMC) by Ministry of Health. A pilot project was carried out by the Danish-Vietnamese Study Group. The immediate objects were: to provide basic epidemiological information about ARI in southern Vietnam, to develop training modules and case management intervention modules at primary and secondary level in order to enable mothers, village workers, health post staff and district hospital emergency department staff to treat moderate and severe pneumonia and acute bronchitis in accordance with the WHO management guide for ARI and to evaluate the effect of those modules after implementation in a limited number of communes. The modules were developed at PHN1. Ten commune health stations were carefully selected. The purpose of the project and the conditions for taking part had been explained to the health workers. The doctors and other commune health workers from the 10 commune health stations and doctors from the connected district hospitals attended the training courses at PHN1, HCMC and also at the belonging provincial hospitals. Essential equipment was provided and a pharmacy with essential drugs established. The registered health statistics was collected yearly during on site visits. The local doctors and commune health workers gave seminars for mothers in the villages of the 10 project communes. The mothers' knowledge, attitude and practice (KAP) was tested in interviews before and two months after the seminars had taken place. The spread of KAP was measured by random interviews of mothers six month later. In the interviews information on social conditions was obtained. The mothers' KAP had risen by 25% two months after attending the seminars. A further increase of KAP by 5-10% within the untrained group appeared in a survey 4-6 months later. It was not possible to obtain reliable statistics on morbidity or mortality of ARI in the project area.
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PMID:Development of ARI case management at primary and secondary level in southern Vietnam. 1141 10

In a health facility-based study to determine the knowledge of mothers regarding recognition of pneumonia in their pre-school children, 400 women were interviewed using a pre-tested structured questionnaire. Sixty-one per cent of them would recognise pneumonia by difficult breathing, 42% by fast breathing and 26.5% by severe cough. Few of the mothers mentioned signs suggestive of 'chest indrawing' (8.5%) and 'central cyanosis' (1%). The maternal knowledge score on pneumonia signs increased significantly with educational status and social class (p < 0.05). While a substantial number of mothers (51%) perceived fast breathing to be an indication of severe pneumonia, a sizeable number (87.5%) were unsure if late signs such as chest indrawing and central cyanosis suggested severe disease. On the basis of the WHO criteria, it is concluded that maternal recognition of pneumonia in children is at best modest while knowledge of signs indicating severe disease is poor. These findings underscore the need to modify the WHO criteria to include difficult breathing and to highlight during local ARI health education campaigns that late signs such as chest indrawing and central cyanosis indicate severe and potentially fatal pneumonia.
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PMID:Maternal perception of pneumonia in children: a health facility survey in Enugu, eastern Nigeria. 1236 95


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