Assessing the Quality of Care for Pneumonia in Integrated Community Case Management: A Cross-Sectional Mixed Methods Study

PLoS One. 2016 Mar 24;11(3):e0152204. doi: 10.1371/journal.pone.0152204. eCollection 2016.


Background: Pneumonia is the leading infectious cause of mortality in children under five worldwide. Community-level interventions, such as integrated community case management, have great potential to reduce the burden of pneumonia, as well as other diseases, especially in remote populations. However, there are still questions as to whether community health workers (CHW) are able to accurately assess symptoms of pneumonia and prescribe appropriate treatment. This research addresses limitations of previous studies using innovative methodology to assess the accuracy of respiratory rate measurement by CHWs and provides new evidence on the quality of care given for children with symptoms of pneumonia. It is one of few that assesses CHW performance in their usual setting, with independent re-examination by experts, following a considerable period of time post-training of CHWs.

Methods: In this cross-sectional mixed methods study, 1,497 CHW consultations, conducted by 90 CHWs in two districts of Luapula province, Zambia, were directly observed, with measurement of respiratory rate for children with suspected pneumonia recorded by video. Using the video footage, a retrospective reference standard assessment of respiratory rate was conducted by experts. Counts taken by CHWs were compared against the reference standard and appropriateness of the treatment prescribed by CHWs was assessed. To supplement observational findings, three focus group discussions and nine in depth interviews with CHWs were conducted.

Results and conclusion: The findings support existing literature that CHWs are capable of measuring respiratory rates and providing appropriate treatment, with 81% and 78% agreement, respectively, between CHWs and experts. Accuracy in diagnosis could be strengthened through further training and the development of improved diagnostic tools appropriate for resource-poor settings.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Community Health Workers*
  • Cross-Sectional Studies
  • Female
  • Humans
  • Male
  • Pneumonia / diagnosis*
  • Pneumonia / epidemiology*
  • Pneumonia / pathology
  • Pneumonia / therapy
  • Quality of Health Care*
  • Rural Population
  • Zambia

Grant support

The study was conducted through COMDIS-HSD (, a research programme consortium funded by UK aid from the UK government ( KG, MM, SN, PH and RK were funded through this grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This research study was conducted alongside implementation of iCCM in Luapula Province in Zambia funded by CIDA (now Global Affairs Canada, from 2009–2013 (grant number M012955-001). CS, SM and HC were funded through this grant. Some of the activities and materials for the study were therefore supported by funding from CIDA.