Health Workers' Practices in Assessment and Management of Children with Respiratory Symptoms in Primary Care Facilities in Uganda: A FRESH AIR Descriptive Study.

INTRODUCTION: Globally, acute lower respiratory infections are the leading cause of mortality among children under 5 years. Following World Health Organization primary care guidelines, pneumonia is diagnosed based on cough/difficult breathing and fast breathing. We aimed to describe the practices of healthcare workers in primary care health facilities in Uganda in the management of young children with respiratory symptoms especially regarding asthma as opposed to pneumonia. METHODS: Health workers were observed during clinical consultations with children 1-59 months of age presenting with cough and/or difficult breathing at recruitment. Afterward, an exit interview with the caregiver was conducted. Health center availability of clinical guidelines, equipment and supplies for management of children with respiratory symptoms was assessed systematically. RESULTS: A total of 218 consultations with 50 health workers at six health centers were included. Median consultation time was 4 min. Health workers asked history relevant to distinguishing asthma from pneumonia in 16% of consultations. The respiratory rate was counted in 10%. Antibiotics were prescribed to 32% of all the children and to 39% of children diagnosed with pneumonia. Caregivers reported being informed of findings and possible diagnosis in 5% of cases. Medicine and equipment needed for diagnosing and treating asthma were generally unavailable. CONCLUSION: Clinical practices among Ugandan health workers in primary care are insufficient to distinguish between main causes of respiratory symptoms, especially asthma as opposed to pneumonia, in children under five. Irrational use of antibiotics is widespread. Clear communication with caregivers is lacking. This could be due to lack of relevant competencies, medicines, time and supplies. LAY SUMMARY: Globally, the most frequent cause of death for children under five is infections in the lower airways. The World Health Organization recommends that in local health clinics this is defined as cough/difficult breathing and fast breathing. This article focuses on the practices of local health workers in Uganda and how they in practice diagnose and treat children under five with these symptoms. In addition, we try to estimate how much the caregivers of the children understand from the consultation. This is done by observing the healthcare workers (HCWs) and by interviewing the caregivers. In general, we found that the consultations were too short, that too few of the health workers looked for important signs for lower airways disease such as fast breathing and that antibiotics were prescribed in too many of the consultations. Also, the length and quality of the consultations and the supplies at the local health clinics were not sufficient to diagnose and treat asthma, which can often be mistaken for an infection. We believe that it is an important problem that too few children with asthma are being diagnosed correctly and that antibiotics are being prescribed too frequently, the latter being an important cause of antibiotic resistance. Relevant action must be taken to improve this.

No time for change? Impact of contextual factors on the effect of training primary care healthcare workers in Kyrgyzstan and Vietnam on how to manage asthma in children - A FRESH AIR implementation study.

BACKGROUND: Training is a common and cost-effective way of trying to improve quality of care in low- and middle-income countries but studies of contextual factors for the successful translation of increased knowledge into clinical change are lacking, especially in primary care. The purpose of this study was to assess the impact of contextual factors on the effect of training rural healthcare workers in Kyrgyzstan and Vietnam on their knowledge and clinical performance in managing pediatric patients with respiratory symptoms. METHODS: Primary care health workers in Kyrgyzstan and Vietnam underwent a one-day training session on asthma in children under five. The effect of training was measured on knowledge and clinical performance using a validated questionnaire, and by direct clinical observations. RESULTS: Eighty-one healthcare workers participated in the training. Their knowledge increased by 1.1 Cohen's d (CI: 0.7 to 1.4) in Kyrgyzstan where baseline performance was lower and 1.5 Cohen's d (CI: 0.5 to 2.5) in Vietnam. Consultations were performed by different types of health care workers in Kyrgyzstan and there was a 79.1% (CI 73.9 to 84.3%) increase in consultations where at least one core symptom of respiratory illness was asked. Only medical doctors participated in Vietnam, where the increase was 25.0% (CI 15.1 to 34.9%). Clinical examination improved significantly after training in Kyrgyzstan. In Vietnam, the number of actions performed generally declined. The most pronounced difference in contextual factors was consultation time, which was median 15 min in Kyrgyzstan and 2 min in Vietnam. DISCUSSION AND CONCLUSION: The effects on knowledge of training primary care health workers in lower middle-income countries in diagnosis and management of asthma in children under five only translated into changes in clinical performance where consultation time allowed for changes to clinical practice, emphasizing the importance of considering contextual factors in order to succeed in behavioral change after training.

Childhood asthma in low income countries: an invisible killer?

Bacterial pneumonia has hitherto been considered the key cause of the high respiratory morbidity and mortality in children under five years of age (under-5s) in low-income countries, while asthma has not been stated as a significant reason. This paper explores the definitions and concepts of pneumonia and asthma/wheezing/bronchiolitis and examines whether asthma in under-5s may be confused with pneumonia. Over-diagnosing of bacterial pneumonia can be suspected from the limited association between clinical pneumonia and confirmatory test results such as chest x-ray and microbiological findings and poor treatment results using antibiotics. Moreover, children diagnosed with recurrent pneumonia in infancy were often later diagnosed with asthma. Recent studies showed a 10-15% prevalence of preschool asthma in low-income countries, although under-5s with long-term cough and difficulty breathing remain undiagnosed. New studies demonstrate that approximately 50% of acutely admitted under-5s diagnosed with pneumonia according to Integrated Management of Childhood Illnesses could be re-diagnosed with asthma or wheezing when using re-defined diagnostic criteria and treatment. It is hypothesised that untreated asthma may contribute to respiratory mortality since respiratory syncytial virus (RSV) is an important cause of respiratory death in childhood, and asthma in under-5s is often exacerbated by viral infections, including RSV. Furthermore, acute respiratory treatment failures were predominantly seen in under-5s without fever, which suggests the diagnosis of asthma/wheezing rather than bacterial pneumonia. Ultimately, underlying asthma may have contributed to malnutrition and fatal bacterial pneumonia. In conclusion, preschool asthma in low-income countries may be significantly under-diagnosed and misdiagnosed as pneumonia, and may be the cause of much morbidity and mortality.

Correction: Diagnosis and treatment of acute respiratory illness in children under five in primary care in low-, middle-, and high-income countries: A descriptive FRESH AIR study.

[This corrects the article DOI: 10.1371/journal.pone.0221389.].

Author Correction: Recurrent lower respiratory illnesses among young children in rural Kyrgyzstan: overuse of antibiotics and possible under-diagnosis of asthma. A qualitative FRESH AIR study.

The original version of this Article contained an error in the spelling of the author Mette Marie Kristensen, which was incorrectly given as Mette-Marie Kristensen. The affiliation details for Mette Marie Kristensen were also incorrect in this Article. This has now been corrected in both the PDF and HTML versions of this article.

Recurrent lower respiratory illnesses among young children in rural Kyrgyzstan: overuse of antibiotics and possible under-diagnosis of asthma. A qualitative FRESH AIR study.

Lower respiratory tract illnesses (LRT-illnesses) in children under 5 years (U5s) are a leading cause of morbidity, hospitalisations and mortality worldwide, particularly in low-income countries. It is pertinent to understand possible inconsistent management. This study explored perceptions and practices among caregivers and health professionals on recurrent LRT-illnesses in U5s. Semi-structured interviews with 13 caregivers to U5s with recurrent LRT-illnesses and with 22 primary care health professional interviews in two rural provinces in Kyrgyzstan were triangulated. Data were thematically analysed. The majority (8/13) of caregivers described their young children as having recurrent coughing, noisy breathing and respiratory distress of whom several had responded positively to acute salbutamol and/or had been repeatedly hospitalised for LRT-illness. Family stress and financial burdens were significant. The health professionals classified young children with recurrent LRT-illnesses primarily with pneumonia and/or a multitude of bronchitis diagnoses. Broad-spectrum antibiotics and supportive medicine were used repeatedly, prescribed by health professionals or purchased un-prescribed by the caregivers at the pharmacy. The health professionals had never applied the asthma diagnosis to U5s nor had they prescribed inhaled steroids, and none of the interviewed caregivers' U5s were diagnosed with asthma. Health professionals and caregivers shared a common concern for the children's recurrent respiratory illnesses developing into a severe chronic pulmonary condition, including asthma. In conclusion, the study identified an inconsistent management of LRT-illnesses in U5s, with exorbitant use of antibiotics and an apparently systemic under-diagnosis of asthma/wheeze. When the diagnosis asthma is not used, the illness is not considered as a long-term condition, requiring preventer/controller medication.

A young child with a history of wheeze.

The parents of a 3-year old boy are anxious about their son who has recurring episodes of wheezing. They are frustrated that no one seems to be able to give them answers to their questions and would like a referral to a specialist. Does their son have asthma and what is the prognosis; how can the recurrent wheezing be managed and can the risk of asthma be reduced; are there lifestyle changes that could improve the environment and avoid triggers? Communication and support from the family practice team were essential. Listening to the parents' concerns, explaining the diagnostic uncertainty, being realistic about what drug treatments could achieve, and providing practical advice on inhaler use and trigger avoidance reassured the parents that there was a strategy for managing their son's wheeze. The specialist referral was postponed.

International Primary Care Respiratory Group (IPCRG) Guidelines: management of asthma.

Worldwide, most patients with asthma are treated in primary care. Optimal primary care management of asthma is therefore of considerable importance. This IPCRG Guideline paper on the management of asthma in primary care is fully consistent with GINA guidelines. It is split into two sections, the first on the management of adults and schoolchildren, and the second on the management of pre-school children. It highlights the treatment goals for asthma and gives an overview of optimal management including the topics which should be covered by the primary care health professional when educating a patient about asthma. It covers the classification of the disease, the stepwise approach to pharmacologic therapy, disease monitoring, the management of exacerbations, and the identification of patients at risk of asthma death.

Exacerbations of chronic obstructive pulmonary disease--a patients' perspective.

BACKGROUND: Exacerbations are now an important clinical variable for research into, and management of, chronic obstructive pulmonary disease (COPD). Emphasis is usually on reductions in the incidence of exacerbations and their impact on quality of life. For such research to be useful and comparable there needs to be a clearly defined understanding of what is meant by the term 'exacerbation'. The aim of this study was to explore the notion of COPD exacerbations from the viewpoint of patients who had recently suffered an exacerbation. METHODS: Using principles from grounded theory we conducted semi-structured, in-depth interviews with 23 volunteers from Denmark, the Netherlands and the UK who were identified as having had a COPD exacerbation. Interviews were recorded locally and translated into English for analysis. Notable themes were identified for each informant and their occurrences compared. RESULTS: Patients' reasons for consulting fell into four categories: 'frightening change'; 'change in sputum colour'; 'gradual deterioration'; and 'opportunistic diagnosis'. Most patients consulted frequently about their COPD, but did not afford their exacerbations the same degree of prominence as healthcare professionals (HCPs). CONCLUSIONS: These data provide a new way of thinking about COPD exacerbations, offering a greater understanding and classification of the reasons underlying the decision of COPD patients to consult with HCPs. They suggest that the patient perspective of exacerbations is more complex than previously thought. These findings could be applied to clinical practice and research, facilitating focussed decisions on COPD management.

Childhood asthma: reasons for diagnostic delay and facilitation of early diagnosis--a qualitative study.

BACKGROUND: Children with undiagnosed asthmatic symptoms account for much illness and hospitalisation. The aim of the study was to identify reasons for diagnostic delay in childhood asthma and to develop tools for early diagnosis. METHODS: A qualitative study, using semi-structured interviews with the parents of 30 children with asthma aged 2-15 years, combined with 15 GP interviews. FINDINGS: Asthma symptoms for most of the children started during their first year. The typical symptom pattern reported by parents consisted of insidious recurrent or continuous respiratory symptoms, particularly bad at night, often lasting several weeks or months, provoked or aggravated by common colds or foggy weather. In describing the symptoms, parents focussed on coughing and sputum production. As in other studies, the children's asthmatic diagnosis was obscured by excessive diagnostic emphasis on respiratory infections. The reasons for diagnostic delay seemed to be, typically, that doctors did not pay enough attention to the history of recurrent cough and unspecified respiratory symptoms, just as the parents' use of lay and onomatopoeic terms and metaphors for wheezing seemed to be misinterpreted. Furthermore some doctors relied more on the present symptoms and physical examination, although asthmatic patients may have normal auscultation on examination. Several doctors did not expect asthma in infancy. CONCLUSIONS: The underlying reason for diagnostic delay could be that a former diagnostic definition of asthma, focussing on severe and dramatic cases, was still used by doctors. However, adapting to a new diagnostic concept for asthma, which highlights a history of periodic or chronic cough, wheeze and/or breathing difficulties and the typical asthma pattern in toddlers as shown in this study, may enable earlier diagnosis and treatment.

Hay fever and a single intramuscular injection of corticosteroid: a systematic review.

OBJECTIVES: In severe hay fever, some patients are strongly affected despite the use of first-line therapy and are therefore treated with an intramuscular injection of systemic corticosteroid (i.m. SCS) in some countries. The aim of this paper was to explore the efficacy and side effects of a single i.m. SCS injection in hay fever in adults. DATA SOURCES: PubMed, EMBASE, Cochrane Library. METHODS: Systematic review. Criteria for inclusion: hay fever or seasonal allergic rhinitis, adults, injectable steroids, clinical trials, English language. None of the clinical trials were excluded, since an important aim of the review was to identify any possible side-effects. OUTCOME MEASURES: clinical effects, and clinical and physiological side-effects. RESULTS: 18 clinical trials met the inclusion criteria: nine double-blind RCTs (five placebo-controlled and four comparative RCTs), two single-blinded RCTs, and seven open trials. All studies were conducted before 1988. The efficacy of a single intramuscular injection of SCS was statistically significant in all five placebo-controlled trials and demonstrated considerable clinical benefit, lasting approximately from within the first day to four weeks. In the only two studies comparing i.m. SCS to nasal steroids a superior effect with i.m. SCS was demonstrated. The side-effects were few, both clinically and physiologically, with retained ability to respond to stress with hypothalamic-pituitary-adrenal activation. CONCLUSIONS: The studies in this review were sound and their findings consistent: i.m. SCS therapy was shown to be efficient and safe for the treatment of hayfever in adults. This review shows no support for any concerns regarding serious tissue atrophy or other serious side-effects, any long-lasting suppression of plasma-cortisol, or any influence on stress reaction, following a single intramuscular injection of SCS.