Pneumonia Perception Project-Pakistan
Condition: Pneumonia; Perception, Self
MeSH terms: Pneumonia
Study type: Interventional

Summary: 
      Pneumonia and recurrent wheeze contribute extensively to under five childhood morbidity and
      mortality in Pakistan. Among the avoidable causes of death due to these diseases, delayed
      care seeking is a major one whereby around 38% of deaths due to acute respiratory illnesses
      occur in households. Of these cases which die due to delayed care seeking, majority are taken
      for healthcare after 2 days of initiation of symptoms with around 30% been given antibiotics
      at home before seeking healthcare. Around 32% of these cases die at home, 48% in hospitals,
      9% en route, and the 11% in clinics or health centres.This could be due to lack of time, lack
      of funds for healthcare, lack of decision making on the part of the mother or improper carer
      perception of the seriousness of the condition. Thus there are various cultural, social,
      personal and religious factors which affect the care seeking behaviors of caregivers for
      these illnesses. Understanding these aspects of delayed care seeking is critical to develop
      effective intervention strategies to reduce disease related mortality. We, therefore, aim to
      establish an understanding of perception of under-five pneumonia and recurrent wheeze among
      caregivers of children under five along with associated factors of delayed care seeking in
      selected communities in Pakistan. The results of this study will permit us to design an
      effectiveness study which can be used by program managers and policy makers to develop
      program strategies to reduce childhood deaths due to delayed care seeking for these diseases.
    

Detailed description: 
      Background: In Pakistan, pneumonia and recurrent wheeze in children under five pose
      significant threats to children's health. Despite being preventable, more than 90,000
      children die each year due to pneumonia in Pakistan, making it one of the top five countries
      in the world, with the highest pneumonia related childhood mortality. Similarly, children
      account for 20%-30% of the 2 million Pakistani asthma patients. The predisposing factors
      which lead to these illnesses include lack of hygiene, lack of immunization, overcrowding,
      household air pollution, smoking and poverty. Prompt recognition and timely initiation of
      treatment is imperative in children under five with pneumonia and recurrent wheeze and
      failure to do so can lead to complications and death.

      In children under five, among the causes of death due to these diseases, one is delayed care
      seeking. It has been identified that around 38% of deaths due to respiratory illnesses occur
      in households due to this delayed care seeking which is defined as delay in care sought for
      an illness outside home. This delay is referred to as the time taken by the caregiver to seek
      healthcare later than what would have been optimal.

      In most of the Low middle income countries (LMICs), carer gender plays an important role in
      decisions to seek care. Although in majority of households, the primary caregivers of
      children under five are the mothers of those children, decisions with respect to care are
      often made by fathers or mothers in law which is a problem as they do not cater to the child
      in a timely manner either by not being there or being ignorant of basic management of the
      illness. Another contributing factor could be lack of time to take the child for healthcare
      as the mothers are usually occupied in their household chores and the fathers are busy
      working. And in rare cases where either the mother of a child dies at childbirth (500 per
      100,000 live births) and when fathers are working away from home, it is the secondary
      caregiver who is responsible for care-seeking of that child. He/she could be an aunt/uncle or
      neighbour. But in such cases often the child is neglected due to other priorities of the
      secondary caregivers.

      Although well-proven life-saving tools are available to stop mortality due to preventable
      illnesses like pneumonia and recurrent wheeze, the existing health systems in Pakistan are
      passive. Here, healthcare providers tend to wait for patients to come to them but the later
      the patients with acute respiratory illness come, the more likely they are to die. World
      Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF)
      have, therefore, emphasized the development of innovative, sustainable and cost-effective
      strategies/interventions to improve child health. It is important to devise a strategy
      whereby patient's symptoms are identified timely and immediate care given at their doorstep.
      Experimental studies provide the strongest evidence that illness perceptions can modify
      behaviours and care-seeking, and several studies have shown that interventions designed to
      change illness perceptions can improve health outcomes. Locally adapted behaviour change
      communication may reduce the incidence of severe pneumonia and could be a key component in
      national child-health strategies.

      One of the most impactful strategies can be timely healthcare seeking through community
      health workers who have been a powerful force to promote healthy behaviours and extend the
      reach to the health system by acting as a bridge between the community and the system.
      Community-based packaged interventions delivered through CHWs have been shown to improve care
      seeking for childhood illnesses. In Pakistan, these CHWs are referred to as Lady Health
      Workers (LHWs) enrolled under the National Program for Family Planning and Primary
      Healthcare. On average each LHW covers 100-150 households by making monthly visits and
      providing basic health services and education on health and wellbeing. These LHWs could,
      therefore, be a useful mode of active pneumonia and recurrent wheeze case finding and
      information sharing to counsel against development of acute respiratory infections as
      evidence has shown that health interventions integrating Community Health Workers (CHWs) can
      lead to positive behaviour changes and lower morbidity and mortality rates, while moving
      services and information closer to the communities where they are actually needed.

      Objective: Our study will explore healthcare care-seeking for childhood pneumonia and
      recurrent wheeze among caregivers of children under five through a qualitative approach.
      Further, we aim to devise a Care Model to actively find cases through LHWs and promote
      appropriate care seeking behaviour among the caregivers.
    

Intervention name(s): Mobile Health (mHealth) for Pneumonia
Intervention type(s): Behavioral
Intervention description(s): Audiovisual mobile based application will be used to counsel caregivers of children under five on pneumonia and its prevention. This will be coupled with text and voice message dissemination to the cell phones of caregivers and active pneumonia case finding by the LHWs which will be managed according to severity.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Prevention